Job description

Job responsibilities

Purpose of the role

Social Prescribing empowers people to take control of their health & wellbeing through referral to non-clinical Social Prescribing link workers, allowing them time to focus on what matters to me, taking a holistic approach to an individuals health and wellbeing needs in a supportive manner, to increase confidence to live a more independent life within their local community.

Support people by connecting them to non-medical, community-based activities, groups and services that meet their practical, social and emotional needs, including specialist advice services, arts and culture, physical activity, and nature- and green-based activities.

Supporting the development of accessible and sustainable community offers by working in partnership with Voluntary Care Service Enterprise organisations, VCSE, local authorities and others to identify gaps in provision, and take a community development approach to enabling growth in community activities and groups. Using coaching and motivational interviewing techniques to support people.

Social Prescribing link workers:

Take a whole population approach, working with a range of people who may benefit from social prescribing, including lonely people, who have complex social needs, low-level mental health needs, long-term conditions, as well as working with priority populations identified by the Primary Care Network, PCN as outlined in the Network Contract DES

Help people to identify issues that affect their health & wellbeing and co-produce a simple personalised care and support plan using the Social Prescribing template. Together, the patient and Social Prescriber will set small, achievable goals, focusing on what is important to the person. Goals will be supportive and reviewed regularly with the person.

Empower people to take control of their own health and wellbeing.

Key Responsibilities

Take referrals from the PCNs Core Network Practices and from a wide range of agencies, including pharmacies, health and care multi-disciplinary teams MDTs, and welfare advice services, VCSE organisations, and through self-referrals list is not exhaustive.

Promote social prescribing as an approach across the PCN and wider agencies,

including its role in supported self-management, in addressing health inequalities and the wider determinants of health, reducing pressure on statutory services, improving access to healthcare and improving health outcomes, and in taking a holistic approach to care.

.Proactively encouraging equitable participation in social prescribing through taking self-referrals and connecting with diverse local communities through a range of methods, particularly communities that statutory agencies may find hard to reach and where health inequalities are most prevalent, ensuring that those people self-referring have equal opportunities

Provide information and guidance on what the person can do for themselves to improve their health and wellbeing

Provide follow-up support to the person to ensure they are happy, able to engage, feel included and that they are receiving good support.

Seek regular feedback via surveys, feedback forms, about the quality of service and the impact of social prescribing on referral agencies

Help people maintain or regain independence through living skills, enablement approaches and simple safeguards

Helping people to gain skills for meaningful employment, where appropriate.

Seek advice and support from the General Practitioner GP, supervisor and/or identified individuals to discuss safeguarding concerns and follow PCN safeguarding policies around reporting and/or escalating concerns.

Make appropriate onward referrals. Empower people where possible to reach out to their GP practice, care provider, ensuring they have relevant contact information to hand at all times.

Develop supportive relationships with local Voluntary Care Sector Enterprise, VCSE organisations, community groups and statutory services, to understand their offer and make timely, appropriate and supported referrals

Promote diversity and inclusion when developing or supporting new community groups.

Encourage people who have been connected to community support through social prescribing to volunteer or to start their own activities and groups

Support existing local volunteering schemes to strengthen community resilience and explore potential to develop a team of volunteers to provide buddying support, peer support or to start new community-based groups or activities.

Data capture

Support referral agencies to provide appropriate information about the person they are referring, including demographic data and data on wider determinants, for example, caring status, any safeguarding concerns.

Provide appropriate and timely feedback to referral agencies about the people they referred.

Work sensitively with people, their families and carers to capture key information to measure impact of social prescribing on their health and wellbeing, using validated tools determined locally such as the ONS4 wellbeing scale to assess need and measure outcomes.

Encourage people, their families and carers to provide feedback on their experience, for example, through patient satisfaction surveys, and to share their stories about the impact of social prescribing on their lives.

Ensure that social prescribing referral SNOMED codes are coded appropriately into clinical systems as outlined in the Network Contract DES using the Social Prescribing template aligns to Personalised care and Support Plan

Adhere to PCN policies around data protection legislation and data sharing agreements, ensuring people give appropriate consent. at the start of the episode of care with the Person/ Patient.

Provide monthly data feedback as required by the PCN. Using current and any future data collection systems in a timely manner.

Continuing professional development

Work with a supervisor and/or line manager to undertake continual personal and professional development in line with the social prescribing Workforce Development Framework Competency Framework, including:

Work with your supervising GP and/or line manager to access regular clinical/non-managerial supervision

Take an active role in reflecting, reviewing and developing professional knowledge, skills and behaviours

Attend appropriate mandatory training before working with people and be aware of own competence, maintaining boundaries, both personal & around scope of practice and referring onwards for people whose needs fall outside of these boundaries

Adhere to organisational policies and procedures, including confidentiality, safeguarding, lone working, information governance, equality, diversity and inclusion training and health and safety.

https://www.england.nhs.uk/publication/workforce-development-framework-social-prescribing-link-workers/

Miscellaneous

Establish strong working relationships with GPs, practice teams and relevant multidisciplinary teams and work collaboratively with other health Social Prescribers, Health and Wellbeing coaches, Mental Health and Wellbeing coaches, care co-ordinators, supporting each other, respecting each others views and meeting regularly as a team.

Act as a champion for Social Prescribing, as a part of the PCNs personalised care offer for patients and organisations

Demonstrate a flexible attitude and be prepared to carry out other duties as may be reasonably required from time to time within the general character of the post or the level of responsibility of the role, ensuring that work is delivered in a timely and effective manner.

Identify opportunities and gaps in the service - and review risks and issues that could impact on service delivery - and provide feedback to continually improve the service and contribute to business planning.

Work in accordance with the practices and PCNs policies and procedures.

Contribute to the wider aims and objectives of the PCN to improve and support primary care, working to the PCNs priorities in accordance with the DES.

Work as part of the MDT, to seek feedback, promote the benefits of Social Prescribing value to patients, carers and the system. Continually work and engage to improve the service

Undertake any tasks consistent with the level of the post and the scope of the role, ensuring that work is delivered in a timely and effective manner.

Duties may vary from time to time, without changing the general character of the post or the level of responsibility.

Person Specification

Qualifications

Essential

• Completed a PCI accredited Social Prescriber training course or be willing to complete one prior to taking referrals.
• Compassionate, reflective and self-aware and will enjoy working with a wide range of people
• Able to provide a culturally sensitive, inclusive service, by supporting people from all backgrounds and communities, respecting lifestyle, equality, diversity and providing high quality, non-judgemental support.
• The candidate will be compassionate, reflective & self-aware, will enjoy working with a wide range of people.
• Commitment to reducing health inequalities and proactively working to reach people from diverse communities.
• Able to support people in a way that inspires trust and confidence, motivating others to reach their potential, adapting to individual levels of activation and health literacy.
• They will be a commitment to collaborative working with a keen team work ethic, working alongside, local agencies (including VCSE organisations and community groups) Able to work with others to reduce hierarchies within the community.
• Can demonstrate personal accountability, emotional resilience and ability to work under pressure, having a proactive and flexible attitude, ability to work using own initiative.
• Experience of working in a multidisciplinary team with demonstrable networking experience
• NVQ Level 3, Advanced level or equivalent qualifications or working towards. Reflective listening skills.

Desirable

• Experience of working in health and social care care/community development setting or similar
• Relevant training and experience in Self-Management Education(SME)
• Experience of successful partnership working across statutory, voluntary and community sector.

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.

Certificate of Sponsorship

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).

Employer details

Employer name

Allied Health South Lincolnshire Limited

Address

AHSL

Abbeyview Medical Centre

Thorney Road

Crowland

Peterborough

PE6 0AL

United Kingdom

Employer's website

https://slrpcn.co.uk/ (Opens in a new tab)

Job description

Job responsibilities

General duties

Health and Safety- It is the responsibility of the individual to work in compliance with all current Health and Safety legislation and the Practice Health and Safety Policy. To attend any training requirements, both statutory and mandatory, in line with the legal responsibility to comply with the Health and Safety at Work Act.

The roles contains the following responsibilities:

To maintain registration with the NMC.

To adhere to the NMC Code.

To support training and development.

To maintain personal professional competency and appropriate development.

To carry out the duties and responsibilities of the post in accordance with the Practice Policies including duty of candour and whistleblowing.

Required to comply with all relevant national and local statutory and mandatory requirements including Health and Safety, Infection Control, Safeguarding, Information Governance, Research Governance and Equality and Human Rights.

To implement and review individual care plans, a self-management plans and to agree trigger thresholds to contact Case Managers / GPs.

Plan visits to housebound people, undertake every 3-6 months, and arrange care plans where necessary

Provide enhanced support to Nursing and Residential home with a focus on strengthening relationships and improving access through information sharing, education and advice.

Planned visits to Nursing and Residential homes to be undertaken every 3-6 months, providing training as required.

To ensure all people in Nursing and Residential homes have care plans (including dementia where needed) and to provide a holistic review of all people in these homes with updates of their care plans.

To contact people where necessary to advise them of the role of Specialist Neighbourhood Nurse

Visit people at home following the identification of urgent clinical need including those escalated by EMAS or a member of the Neighbourhood Team, undertake a personalised comprehensive assessment, in order to diagnose, treat and prescribe within the limitations of your registration and competence

Visit people at home following an unplanned hospital admission and those with a history of repeat admissions, within 2 weeks.

Contact those that have suffered a bereavement.

Arrange dedicated appointments in practice, for those who wish to visit, with flexibility to expand up to 30 minutes, or as needed.

. Key Responsibilities

Act as a point of contact between GP, Neighbourhood Team, people and their carers.

Develop and maintain a detailed knowledge of local services to enable supported signposting of people with identified need, sharing information with the Neighbourhood Team.

Liaise with GPs and practice teams to identify people who are elderly, frail or who have long term health needs and support.

Liaise with primary, secondary and specialist care services as required.

Work with the Neighbourhood Team to help identify people at risk of loss of independence or admission to hospital as a result of inadequate social support.

Provide these cohorts of people signposting to identified services in order to maintain their independence and improve their health and well-being.

Visit people in community, home or care home settings to assess and discuss their care needs involving carers as appropriate.

Implement personal care plans for individual people, ensuring preventative actions are detailed to support the appropriate use of services.

Communicate the care plan to the GP and any other members of the Neighbourhood Team involved in the persons care and upload to the relevant records.

Ensure that identified people receive the right level of help at the right time and help them to experience a joined-up service by liaising with relevant members of the Neighbourhood Team.

Work with patient, carers and the Neighbourhood Team to encourage the patient to adopt effective self-management and self-help seeking approaches to reduce unnecessary hospital admissions.

Liaise with other agencies to ensure timely and appropriate engagement as required.

Support people to access community care assessments as well as carers assessments.

Where a personal healthcare budget is allocated provide advice as required regarding the key choices the patient will need to make.

Identify unpaid carers and direct them to access services as appropriate to provide them with support.

Identify when urgent action or a step up in care is required and promptly alert the relevant member of the Neighbourhood Team, highlighting any safety concerns.

Follow up on communications from out of hospital and in-patient services regarding changes in condition of people to support the practice to respond proactively to potentially unmet needs.

Undertake visits or telephone contact to manage people on the SNNs case load following any unplanned hospital admissions where appropriate.

Participate in Practice multi-disciplinary meetings to discuss Practice people actively being managed by the Neighbourhood Team and any other people from the SNNs case load needing discussion.

To attend Neighbourhood Team MDT meetings at the Practice plus any other meetings where there is a need to discuss Practice patients.

Undertake visits or arrange appointments at the Practice for people on the SNNs case load or otherwise as directed by the Duty Doctor following identification of urgent and non-urgent clinical need to assess, diagnose, treat, prescribe and refer appropriately according to the patients health needs and acting within the SNNs clinical skill set.

Maintain accurate and up to date records of patient contacts using GP record systems and other IM&T systems relevant to the role i.e. entering notes onto Systmone / EMIS using agreed read codes and VMDT

To run regular patient searches using Systmone / EMIS in order to have an up-to-date record of progress of achievement of Key Performance Indicators.

Work with South Lincolnshire ICB, Neighbourhood Teams and other agencies to support and further develop this role.

Support the Practice Manager in providing KPI reports for submission as requested.

5. Key Working Relationships

Practice teams

Neighbourhood Team

Community health services

Specialist teams heart failure, diabetes etc.

Specialist nursing services e.g. St Barnabas

Hospital teams including ward, A&E, discharge and AIR teams

Social Prescribers

Health & Wellbeing Coaches

Safeguarding agencies

Pharmacists

South Lincolnshire ICB

Adult Social Care

Voluntary Services

Independent Care Homes

Local Authority teams

Independent living teams

Person Specification

Knowledge and skills

Essential

• The post holder will work in an environment where individual differences and the contributions of all staff are recognised and valued. All employees, people, carers and the public are entitled to be treated with dignity and respect and no form of discrimination, intimidation, bullying or harassment will be tolerated. We understand, encourage and celebrate diversity, making the NHS a place where we all feel we belong."

Desirable

• IT skills
• Knowledge of Personalisation, and personalised care, that gives people control over their health & care ,based on their needs and what's important to them.
• It's intended to improve health & wellbeing by helping people make decisions about their care, and by making the most of the skills and potential of people, families and communities.

Experience

Essential

• Experience of dealing with people with long term conditions
• Evidence of ability to work autonomously
• Evidence of working within a multidisciplinary team

Desirable

• Experience of working in Primary Care
• Experience of working in a GP practice

Qualifications

Essential

• Registered Nurse Level One
• Post graduate study in health-related studies relevant to long term conditions or equivalent experience
• Evidence of continuing professional development
• Post registration teaching qualification or willingness to undertake
• Post registration qualification in non-medical prescribing or willingness to undertake as needs of service change

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.

Certificate of Sponsorship

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).

Employer details

Employer name

Allied Health South Lincolnshire Limited

Address

Sutton Medical Group

Long Sutton Medical Centre, Trafalgar Square

Long Sutton

SPALDING

Lincolnshire

PE12 9HB

United Kingdom

Employer's website

https://slrpcn.co.uk/ (Opens in a new tab)