Job summary
This is an exciting opportunity to join a new team providing a new model of care across Plymouth, through the establishment of the Inclusion Health Service.
In line with current best practice this service is being developed using the “Pathway” approach, providing ‘end to end’ support for individuals who are homeless. It involves not only medical staff, but a range of multidisciplinary professionals with expertise in social care, housing law and benefits issues, ensuring that a person’s full range of needs are supported. More information about the "Pathway" approach can be found here www.pathway.org.uk
The aim of the Inclusion Health service is:
- To create a comprehensive service, for adults with complex needs related to homelessness, health, contact with the criminal justice system and substance misuse issues.
The Service will:
- Prevent more entrenched and longer-term homelessness.
- Contribute towards improving outcomes and addressing health inequalities for some of the most disadvantaged individuals in Plymouth.
- Achieve truly joined up and effective care and ensure engagement and completion of treatment wherever possible.
Main duties of the job
The post holder be an experienced mental health nurse who will provide care for service users from initial referral, clinical assessment, needs assessment, intervention through to safe discharge.
A key aim will be to engage clients and staff to work collaboratively with the team to address homelessness. The post holder will work in partnership with other members of the multi- disciplinary team, as well as other agencies to achieve successful outcomes. The post holder will have expert knowledge of health, social and housing services within the community.
The post holder will be a resource to others about mental health conditions in the context of homelessness. The post holder will be expected to have in-depth knowledge of the Mental Health and Mental Capacity Acts.
All team members are expected to work collaboratively and supportively with each other across Primary, Secondary Care and Community care boundaries to improve outcomes for people who are homeless.
They should also work to the Pathway model (with flexibility as required), to attend team handover and MDT meetings, and to be present to take referrals, and undertake assessments and ward rounds where needed.
About us
This service will be delivered through an exciting and innovative partnership approach with collaboration from organisations such as Livewell Southwest CIC, Adelaide and St Levan Surgery, University Hospitals Plymouth NHS Trust and the Plymouth Alliance.
Livewell Southwest is a recognised provider of integrated health and social care services operating across South Hams, West Devon and Plymouth www.livewellsouthwest.co.uk
Adelaide and St Levan Surgery is a GP practice in the most deprived area of Plymouth, supporting many adults with complex needs. www.stlevansurgery.nhs.uk
The Plymouth Alliance was formed with a group of local charities / community organisations with leadership from Plymouth City Council to provide services to people with complex needs (homelessness, drug or alcohol misuse, mental illness and offending).
Our Plymouth health and care system requires and features strong and effective collaboration.
This role will be employed by one of these partner organisations.
Leadership
For the right candidate this is one of the roles in the new team that could incorporate the Operational Lead management/team leader responsibilities. Thus, banding could be increased accordingly. Please indicate your interest and experience within your application.
Job description
Job responsibilities
Clinical
- To work autonomously, managing a caseload of patients, whilst working as part of the multidisciplinary team.
- To ensure that the team assess, diagnose, plan, implement and evaluate effective health and social interventions for inpatients experiencing homelessness, and to be available to support and advise on the most complex and high-risk cases.
- To deliver individualised, highly specialised advice to the client group, liaising with necessary support agencies/authorities to achieve the best possible outcome on discharge.
- To have expert knowledge of the physical, mental health and addiction related conditions that commonly effect homeless people and to advise on appropriate inpatient and post discharge care.
- To ensure thorough risk assessment of all service users in line with policy standards.
- To ensure the team assesses capacity and provides safe treatment and care to those who may lack capacity.
- Rapidly and continuously evaluates the patient’s changing condition and response to therapeutic interventions and modifies the plan of care for optimal patient outcome.
- To operate within the legal requirements of the Mental Health Act and be able to exercise independent judgement in the assessment and offering of an opinion on mental health conditions.
- Assess and escalate the need to refer service users presenting with complex long-term conditions (e.g., HIV, Diabetes, Brain Injury,) to appropriate primary and secondary care services as recommended by national and local guidance.
- Maintain relevant clinical and therapeutic knowledge, critically appraise and apply information in practice.
- To ensure the team promotes and delivers evidence-based care for multiply- excluded service users with mental health conditions.
- To ensure the team supports service users to adopt recovery strategies that promote their wellbeing, healthy lifestyle, independence and self-care.
- To ensure the team promotes the involvement of families/carers in patient care reflecting their diversity, equality and rights to ensure patients’ needs are met.
- Participates in planning, development, and implementation of public and community health programmes alongside the Clinical Service Lead.
- To ensure that infection control measures are applied within the team’s practice according to local and national policies.
- To ensure safe staffing levels and oversee appropriate lone working practices.
- Attend multi-disciplinary meetings, taking an active role in patient-centred and service needs planning.
- To follow patients up after discharge as needed, including visiting them in their discharge location as required and to escort patients to appointments if necessary.
- All team members are expected to work collaboratively and supportively with each other across Primary, Secondary Care and Community care boundaries to improve outcomes for people who are homeless.
- They should also work to the Pathway model (with flexibility as required), to attend team handover and MDT meetings, and to be present to take referrals, and undertake assessments and ward rounds where needed.
Communication
The post holder will:
- Communicate the patient’s health, social and housing status using appropriate terminology, format, and technology to all necessary teams and services, both internal and external.
- Use expert communication skills to provide accurate information to service users and their families and carers in a sensitive and professional manner.
- Use and demonstrate sensitive communication strategies to ensure that service users are fully informed and consent to care/ treatment plans.
- Act as an advocate for service users in a number of settings, with an overall aim to gain positive outcomes in housing and onward mental health/physical health support and care.
- Establish effective communication and actively promote health, housing and welfare rights education that may include providing alternative materials to support service users and carers in making decisions regarding their care and treatment.
- Liaise and communicate effectively with multidisciplinary and primary care teams across health, social care and housing boundaries, ensuring timely access to community services.
- Responsible for contributing to the planning of safe and effective discharge of patients and smooth transition of care from inpatient into the community.
- Ensure the team communicates effectively as a whole, including use of productive handovers, MDT meetings and team members’ use of the electronic patient records.
- Maintain accurate and contemporaneous records of health assessment, implementation and evaluation of management and therapeutic interventions.
- Ensure effective liaison with all parts of the service including communication with those responsible for bed management and accurate data collection.
- To suggest and critically explore new concepts without prejudice or assumption.
Professional and Educational
- To work in accordance with the professional Code of Conduct and ensure that standards of practice are upheld.
- To receive regular clinical supervision from the Clinical Service Lead
- Maintain and develop own professional knowledge and competence by keeping informed of advances and research pertaining to mental health care.
- To attend workshops and conferences relating to staff professional group and Homelessness.
- They will contribute to the business planning process and work directly with the Clinical Services Lead on issues related to service developments.
- To contribute to the consultation and engagement of service users in planning and developing services.
- Contribute to the development, implementation and evaluation of evidence-based policies, procedures and guidelines relevant to the care of people with mental health conditions.
Legal and Professional Responsibilities
- Adhere to organisational policies and procedures.
- Maintain a safe environment for all staff and visitors, taking reasonable care to avoid injury.
- To attend regular Health and Safety training.
- Provide statements regarding untoward incidents, as requested by line manager.
- Maintain registration and professional competencies and comply with professional Code of Professional Conduct and related documents.
- To undertake any other duties appropriate to the post and grade.
Values
- Empathy and compassion – providing care for patients that is rooted in the patient’s priorities.
- Collective responsibility – all team members take responsibility for patients and the team’s success, work collaboratively, and support each other.
- Creative persistence – team members tackle complicated problems together, seek practical solutions, and ‘never give up’.
- Challenging discrimination and poor practice – teams support the delivery of equitable health care, challenging poor attitudes, behaviours and practices.
- Inclusive approach to healthcare – teams subscribe to Pathway’s belief that everything about a person’s situation affects their health – not just their medical conditions.
- Promoting autonomy – patient empowerment and individual agency.
- Relationship builders and influencers – form strong networks across all services and influence the behaviour of different stakeholders across those networks including by teaching, training and inspiring others.
- Constantly improving – seeking new opportunities and ways to improve their service, its resilience, and the support it gives to, and receives from, others.
- Trauma-informed – the culture of the whole system, including all work practices and settings reflects a trauma-informed approach.
Additional Information
As a new service we are keen for the successful applicant to bring their expertise and experience to help shape and define the job role and the Health Inclusion Service. Equally, as this new service launches and evolves it may be necessary to review job responsibilities. Therefore, at this stage this is a draft job description.
Job description
Job responsibilities
Clinical
- To work autonomously, managing a caseload of patients, whilst working as part of the multidisciplinary team.
- To ensure that the team assess, diagnose, plan, implement and evaluate effective health and social interventions for inpatients experiencing homelessness, and to be available to support and advise on the most complex and high-risk cases.
- To deliver individualised, highly specialised advice to the client group, liaising with necessary support agencies/authorities to achieve the best possible outcome on discharge.
- To have expert knowledge of the physical, mental health and addiction related conditions that commonly effect homeless people and to advise on appropriate inpatient and post discharge care.
- To ensure thorough risk assessment of all service users in line with policy standards.
- To ensure the team assesses capacity and provides safe treatment and care to those who may lack capacity.
- Rapidly and continuously evaluates the patient’s changing condition and response to therapeutic interventions and modifies the plan of care for optimal patient outcome.
- To operate within the legal requirements of the Mental Health Act and be able to exercise independent judgement in the assessment and offering of an opinion on mental health conditions.
- Assess and escalate the need to refer service users presenting with complex long-term conditions (e.g., HIV, Diabetes, Brain Injury,) to appropriate primary and secondary care services as recommended by national and local guidance.
- Maintain relevant clinical and therapeutic knowledge, critically appraise and apply information in practice.
- To ensure the team promotes and delivers evidence-based care for multiply- excluded service users with mental health conditions.
- To ensure the team supports service users to adopt recovery strategies that promote their wellbeing, healthy lifestyle, independence and self-care.
- To ensure the team promotes the involvement of families/carers in patient care reflecting their diversity, equality and rights to ensure patients’ needs are met.
- Participates in planning, development, and implementation of public and community health programmes alongside the Clinical Service Lead.
- To ensure that infection control measures are applied within the team’s practice according to local and national policies.
- To ensure safe staffing levels and oversee appropriate lone working practices.
- Attend multi-disciplinary meetings, taking an active role in patient-centred and service needs planning.
- To follow patients up after discharge as needed, including visiting them in their discharge location as required and to escort patients to appointments if necessary.
- All team members are expected to work collaboratively and supportively with each other across Primary, Secondary Care and Community care boundaries to improve outcomes for people who are homeless.
- They should also work to the Pathway model (with flexibility as required), to attend team handover and MDT meetings, and to be present to take referrals, and undertake assessments and ward rounds where needed.
Communication
The post holder will:
- Communicate the patient’s health, social and housing status using appropriate terminology, format, and technology to all necessary teams and services, both internal and external.
- Use expert communication skills to provide accurate information to service users and their families and carers in a sensitive and professional manner.
- Use and demonstrate sensitive communication strategies to ensure that service users are fully informed and consent to care/ treatment plans.
- Act as an advocate for service users in a number of settings, with an overall aim to gain positive outcomes in housing and onward mental health/physical health support and care.
- Establish effective communication and actively promote health, housing and welfare rights education that may include providing alternative materials to support service users and carers in making decisions regarding their care and treatment.
- Liaise and communicate effectively with multidisciplinary and primary care teams across health, social care and housing boundaries, ensuring timely access to community services.
- Responsible for contributing to the planning of safe and effective discharge of patients and smooth transition of care from inpatient into the community.
- Ensure the team communicates effectively as a whole, including use of productive handovers, MDT meetings and team members’ use of the electronic patient records.
- Maintain accurate and contemporaneous records of health assessment, implementation and evaluation of management and therapeutic interventions.
- Ensure effective liaison with all parts of the service including communication with those responsible for bed management and accurate data collection.
- To suggest and critically explore new concepts without prejudice or assumption.
Professional and Educational
- To work in accordance with the professional Code of Conduct and ensure that standards of practice are upheld.
- To receive regular clinical supervision from the Clinical Service Lead
- Maintain and develop own professional knowledge and competence by keeping informed of advances and research pertaining to mental health care.
- To attend workshops and conferences relating to staff professional group and Homelessness.
- They will contribute to the business planning process and work directly with the Clinical Services Lead on issues related to service developments.
- To contribute to the consultation and engagement of service users in planning and developing services.
- Contribute to the development, implementation and evaluation of evidence-based policies, procedures and guidelines relevant to the care of people with mental health conditions.
Legal and Professional Responsibilities
- Adhere to organisational policies and procedures.
- Maintain a safe environment for all staff and visitors, taking reasonable care to avoid injury.
- To attend regular Health and Safety training.
- Provide statements regarding untoward incidents, as requested by line manager.
- Maintain registration and professional competencies and comply with professional Code of Professional Conduct and related documents.
- To undertake any other duties appropriate to the post and grade.
Values
- Empathy and compassion – providing care for patients that is rooted in the patient’s priorities.
- Collective responsibility – all team members take responsibility for patients and the team’s success, work collaboratively, and support each other.
- Creative persistence – team members tackle complicated problems together, seek practical solutions, and ‘never give up’.
- Challenging discrimination and poor practice – teams support the delivery of equitable health care, challenging poor attitudes, behaviours and practices.
- Inclusive approach to healthcare – teams subscribe to Pathway’s belief that everything about a person’s situation affects their health – not just their medical conditions.
- Promoting autonomy – patient empowerment and individual agency.
- Relationship builders and influencers – form strong networks across all services and influence the behaviour of different stakeholders across those networks including by teaching, training and inspiring others.
- Constantly improving – seeking new opportunities and ways to improve their service, its resilience, and the support it gives to, and receives from, others.
- Trauma-informed – the culture of the whole system, including all work practices and settings reflects a trauma-informed approach.
Additional Information
As a new service we are keen for the successful applicant to bring their expertise and experience to help shape and define the job role and the Health Inclusion Service. Equally, as this new service launches and evolves it may be necessary to review job responsibilities. Therefore, at this stage this is a draft job description.
Person Specification
Qualifications
Essential
- Recognised Professional Qualification in Nursing (RMN).
- BSc or equivalent experience.
- Evidence of continuing professional development.
Experience
Essential
- Evidence of substantial experience of working directly with homeless clients or clients with addictions.
- Experience of independent / autonomous practice.
- Experience of undertaking holistic health assessments, assessing physical health, social care and mental health needs.
- Experience of case managing clients with complex mental health needs.
- Experience of working with clients from diverse cultural and ethnic backgrounds.
- Substantial relevant post registration experience in a broad range of services.
- Excellent knowledge in the mental health conditions that effect homeless people.
- including dual diagnosis presentations.
- Understanding of homelessness strategies at international, national and local levels.
- Direct experience of working with the benefit system.
- Experience of delivering Service User Initiatives.
- Able to lead in partnership with and negotiate with a wide variety of partnership agencies, and other NHS providers.
- Able to engage, communicate with and empower marginalised clients.
- Negotiation and conflict management skills.
- Strong commitment to improving patient services with a clear focus on achieving performance goals.
- Competence in provision of clinical supervision.
- Competence in IT (incl. email and office packages).
- Excellent interpersonal, communication, negotiation and influencing skills demonstrated by the ability to engage others.
- Excellent written and verbal skills.
Person Specification
Qualifications
Essential
- Recognised Professional Qualification in Nursing (RMN).
- BSc or equivalent experience.
- Evidence of continuing professional development.
Experience
Essential
- Evidence of substantial experience of working directly with homeless clients or clients with addictions.
- Experience of independent / autonomous practice.
- Experience of undertaking holistic health assessments, assessing physical health, social care and mental health needs.
- Experience of case managing clients with complex mental health needs.
- Experience of working with clients from diverse cultural and ethnic backgrounds.
- Substantial relevant post registration experience in a broad range of services.
- Excellent knowledge in the mental health conditions that effect homeless people.
- including dual diagnosis presentations.
- Understanding of homelessness strategies at international, national and local levels.
- Direct experience of working with the benefit system.
- Experience of delivering Service User Initiatives.
- Able to lead in partnership with and negotiate with a wide variety of partnership agencies, and other NHS providers.
- Able to engage, communicate with and empower marginalised clients.
- Negotiation and conflict management skills.
- Strong commitment to improving patient services with a clear focus on achieving performance goals.
- Competence in provision of clinical supervision.
- Competence in IT (incl. email and office packages).
- Excellent interpersonal, communication, negotiation and influencing skills demonstrated by the ability to engage others.
- Excellent written and verbal skills.
Disclosure and Barring Service Check
This post is subject to the Rehabilitation of Offenders Act (Exceptions Order) 1975 and as such it will be necessary for a submission for Disclosure to be made to the Disclosure and Barring Service (formerly known as CRB) to check for any previous criminal convictions.
Applications from job seekers who require current Skilled worker sponsorship to work in the UK are welcome and will be considered alongside all other applications. For further information visit the UK Visas and Immigration website (Opens in a new tab).
From 6 April 2017, skilled worker applicants, applying for entry clearance into the UK, have had to present a criminal record certificate from each country they have resided continuously or cumulatively for 12 months or more in the past 10 years. Adult dependants (over 18 years old) are also subject to this requirement. Guidance can be found here Criminal records checks for overseas applicants (Opens in a new tab).
UK Registration
Applicants must have current UK professional registration. For further information please see
NHS Careers website (opens in a new window).
Additional information
Applications from job seekers who require current Skilled worker sponsorship to work in the UK are welcome and will be considered alongside all other applications. For further information visit the UK Visas and Immigration website (Opens in a new tab).
From 6 April 2017, skilled worker applicants, applying for entry clearance into the UK, have had to present a criminal record certificate from each country they have resided continuously or cumulatively for 12 months or more in the past 10 years. Adult dependants (over 18 years old) are also subject to this requirement. Guidance can be found here Criminal records checks for overseas applicants (Opens in a new tab).
UK Registration
Applicants must have current UK professional registration. For further information please see
NHS Careers website (opens in a new window).