Senior Dementia Practitioner

Dimensions and Context of Role The post-holder is responsible to the Manager of the Plymouth Dementia Pathway (PDP) for the assessment of needs, development, implementation, and evaluation of care for patients from a specified group of patients. The post-holder is responsible for providing care co-ordination to a defined group of people suspected of having memory problems, to determine if further investigation is required for a formal diagnosis of dementia. Once a diagnosis is given, a range of treatment options and post diagnostic support services are offered to enable people with dementia and their relatives/carers to live well with dementia. This includes caseload management of patients diagnosed with dementia who are experiencing BPSD. The post-holder is responsible for caseload management and support to staff within PDP and to provide teaching and supervision to students and others undertaking educational programs. Professional Responsibilities & Patient Contact: The Post-holder will: Be accountable for the direct patient care/support provided by the Plymouth Dementia Pathway at all times. Maintain high standards of clinical/professional care/support of people with dementia, their family/ carers. Work as part of a MDT to ensure that the best possible outcomes are achieved for the person with dementia and their family/carer. Act upon referrals from primary and secondary care, by providing assessment, implementation and development of programmes of care to individuals, groups and families. Have responsibility for own caseload of patients and take responsibility as lead professional or care co-ordinator as appropriate. Provision of case load supervision and line management for Band 3,4 & 5 Practitioners. To participate in Duty cover and provide appropriate supervision for junior team members. To maintain a caseload of clients with a significant degree of BPSD and liaise with suitable MDT for ongoing care and support for the patient and their families. Identify and undertake specialist and comprehensive assessments to assist in the diagnosis of people suspected of having dementia, including the persons: life history, social and family circumstances, and preferences, as well as their physical and mental health needs and current level of functioning and abilities. Be able to inform the person with a suspected dementia and/or their family/carer about the assessment and diagnosis process. Providing knowledge about structural imagining, identifying if they want to have any scans, or if they wish to know the diagnosis and with whom this should be shared with. Take steps to obtain patient consent to care and treatment in accordance with the Mental Capacity Act, ensuring those people with dementia who lack mental capacity remain at the centre of decision-making and are fully safeguarded. Promote a recovery model that empowers people with dementia, their family/ carers to be at the forefront of decision making and ownership of their treatment plans. Assess the effectiveness of medication prescribed for the symptoms of dementia and report observations back to the prescriber as required. Be able to advise on, recommend and provide a range of effective evidence-based treatment and interventions plans at all stages of a persons dementia journey that is based on sound clinical decision making. Promote holistic care and suitable adaptations tailored to each individuals needs. Promoting and maintaining independence of people with dementia by addressing activities of daily living that maximises independent activity, enhances function, adapt and develops skills, and minimises the need for support. Re-assess people with dementia where there are changes in emotional well-being and behaviour. Promote least restrictive practice, maximising independence and freedom, with due attention to the safety of others. Undertake risk assessments, devising and implementing actions and intervention plans which take the risk formulation fully into account. To promote positive risk to allow clients independence and autonomy of choice. Be responsible for decision making and co-ordination in a crisis situation, where necessary seeking advice and guidance from other relevant professionals Be committed to the treatment of people with dementia in the community, reducing the number of inappropriate admissions to acute or in-patient hospital settings. Know when to consider and co-ordinate a psychiatric inpatient admission, making an application for a Mental Health Act Assessment where it is deemed necessary. Complete Social Circumstances Reports and attend the Mental Health Act Tribunals as and when required. Work with staff on the psychiatric inpatient unit to support with discharge planning and joint reviews of patients with dementia who will require ongoing input from the Plymouth Dementia Pathway. Be able to recognise end stage dementia and (when appropriate) liaise with specialists within the end-of-life care team to support in care delivery. Communication and Working Relationship Skills: The Post-holder will: Be able to communicate clearly and effectively with people who have dementia, their family/carers and/or other professionals involved. This will be within the boundaries of confidentiality. Be confident in communicating with people who have dementia or who have difficulties when English is not their first language using organisation approved interpreters/services. Demonstrate a positive attitude, attending to people with dementia their family/carers with respect and courtesy. Be able to receive information, analyse and formulate professional judgements. Be confident in managing conflict between individuals as and when required. Ensure that professional boundaries are always adhered to. Be directly responsible for the collaboration and the planning of individual care with other teams and services to provide a seamless service to people with dementia, their family/carers. Attend and represent the Plymouth Dementia Pathway in meetings, e.g. Child Protection, Adult Protection, Mental Health Tribunals, CPA reviews. Attend and participate in various forums/steering groups within the organisation and the wider community as required. Liaise, advise, develop and maintain good relationships with service users, carers, relatives and fellow health, social care professionals who are involved in the delivery of services. Knowledge and Experience: The Post-holder will: Have experience of working in partnership with people with dementia, and their family/carers in setting such as home environment, care home, hospital etc. Have a sound knowledge of dementia including risk factors and preventative strategies, signs and symptoms, types of dementia and impact. Be aware and able to inform of assessment and diagnostic process for dementia. Demonstrate understanding on treatment options for people diagnosed with dementia including post diagnostic support, cognitive enhancers, other service provisions. Inform others on how to effectively manage behavioural and psychological symptoms in dementia. Practice within the legal and ethical framework set out by mental health related legislation to ensure that service users interests and well-being are at the forefront of care. Adhere to Policy and Legislation relating to Dementia/Mental Health, e.g. Mental Health Act 1983, Mental Capacity Act, Care Act, Equality Act, Human Rights Act, Care Programme Approach and Clinical Governance. Planning and organisational skills: The Post-holder will: Be able to support in the meeting of targets and provide information on a regular basis to enable the team and LSW to perform as expected. Ensure that members of the team are allocated in accordance with their skill mix. Prioritising and delegating accordingly. Ensure that relevant members of the team take a lead in clinical/professional meetings ensuring all patients are reviewed; decisions and plans are put into action and represent the person with dementia and their family/carers views. Attend multi-disciplinary meetings for the protection of people with dementia, family/carers, staff and public e.g. Adult Protection, Case Conference Child Protection, Risk Management. Contribute to the planning and implementation of all service developments within the Plymouth Dementia Pathway, formulating policies and protocols as required. Contribute to the review of the process and procedures within the Plymouth Dementia Pathway in line with Guidance such as: Department of Health and NICE. Analytical and Judgement Skills The Post-holder will: As and when required support in the triage of referrals to the Plymouth Dementia Pathway referring to the eligibility criteria, providing information and advice for those referrals that are not appropriate. Provide dementia care and other interventions in the setting most appropriate to meet the patients needs. Ability to match a person with dementias need with available skills and resources. Take a lead role in crisis assessments, supporting in the identification of risk, formulation of risk management plans and communicate with the wider health and social care community. Report any incidents of harm or near miss in line with the LSW incident reporting policy. Acting appropriately so that actions are taken to reduce the risk of reoccurrence. Supporting in the investigation of complaints and review untoward incidents and serious incidents, producing chronology of events, timelines, gaining witness statements, producing reports, recommendations and action plans for improvements as and when required. Continued in attached job description.