About this role
Job summary
The Enfield Integrated Proactive Care Service is an Enfield Community Services (ECS) Multi-Disciplinary Team (MDT) within the Royal Free London NHS Foundation Trust, operating under the North Middlesex University Hospital (NMUH) unit. The service provides coordinated, person-centred support and interventions for residents living with long-term health conditions and/or frailty, helping them to proactively manage their health and wellbeing through an integrated approach to care.
Working collaboratively with the local authority, acute hospital
trusts, primary care services, and the voluntary sector, the MDT delivers
integrated, person-centred care to Enfield residents who are registered with an Enfield GP, helping to improve health outcomes and support individuals to remain independent within their communities.
The successful candidate will join an ambitious and inclusive partnership that is helping to shape the future of integrated care in Enfield. Working closely with clinicians, community partners, and system leaders, you will play a key role in supporting residents through a more connected, preventative, and person-centred approach to care.
This role offers an exciting opportunity to further develop the Enfield Proactive Care Service Multi-Disciplinary Team (MDT) model and contribute to the design and delivery of an exemplary Integrated Neighbourhood Team (INT).
Main duties of the job
Main duties of the job
1 . Facilitating Access to Local Services Receive and process referrals from GPs and other members of the multidisciplinary team (MDT) for individual patients. Assess patients' needs in line with referral criteria and GP guidance, signposting them to appropriate health, social care, voluntary sector, and community services available within the borough. Support individuals to access services and activities that promote health, wellbeing, independence, and social inclusion, including both funded and self-funded options. Identify unpaid carers and assist them in accessing relevant support services and resources. Work collaboratively with volunteers, supporting their involvement and adhering to established procedures and best practices for volunteer engagement. Provide general information regarding potential benefit entitlements and refer individuals to specialist welfare advice services where appropriate. Develop personalised support plans outlining recommended services and access routes, ensuring relevant information is shared with GPs, carers, and other professionals involved in the individual's care. Maintain comprehensive knowledge of local services, community resources, and eligibility criteria, keeping up to date with service developments and changes. Promote awareness among GPs and healthcare professionals of the range of community-based services available and how these can be accessed.
About us
The Enfield Integrated Proactive Care Service is an Enfield Community Services (ECS) Multi-Disciplinary Team (MDT) within the Royal Free London NHS Foundation Trust, operating under the North Middlesex University Hospital (NMUH) unit. The service provides coordinated, person-centred support and interventions for residents living with long-term health conditions and/or frailty, helping them to proactively manage their health and wellbeing through an integrated approach to care.
Working collaboratively with the local authority, acute hospital
trusts, primary care services, and the voluntary sector, the MDT delivers
integrated, person-centred care to Enfield residents who are registered with an Enfield GP, helping to improve health outcomes and support individuals to remain independent within their communities.
Job description Job responsibilities
MAIN DUTIES AND RESPONSIBILITIESThe post holder will offer World Class Care to service users, staff, colleagues, clients and patients alike so that everyone at the Royal Free can feel:1 . Facilitating Access to Local Services Receive and process referrals from GPs and other members of the multidisciplinary team (MDT) for individual patients. Assess patients' needs in line with referral criteria and GP guidance, signposting them to appropriate health, social care, voluntary sector, and community services available within the borough. Support individuals to access services and activities that promote health, wellbeing, independence, and social inclusion, including both funded and self-funded options. Identify unpaid carers and assist them in accessing relevant support services and resources. Work collaboratively with volunteers, supporting their involvement and adhering to established procedures and best practices for volunteer engagement. Provide general information regarding potential benefit entitlements and refer individuals to specialist welfare advice services where appropriate. Develop personalised support plans outlining recommended services and access routes, ensuring relevant information is shared with GPs, carers, and other professionals involved in the individual's care. Maintain comprehensive knowledge of local services, community resources, and eligibility criteria, keeping up to date with service developments and changes. Promote awareness among GPs and healthcare professionals of the range of community-based services available and how these can be accessed.2. Personalisation Support Support individuals in accessing Community Care Assessments and Carers' Assessments where appropriate. Monitor progress following referrals and liaise with local authority staff and other agencies to help ensure timely access to assessments and support. Provide general guidance regarding personal budgets and available options, including Direct Payments and associated choices, where applicable. Signpost individuals and carers to suitable free, voluntary, community, and statutory services regardless of eligibility for council-funded support. Empower individuals to make informed decisions about their care, support arrangements, and available community resources.3. Care Coordination and Integrated Working Liaise effectively with a range of healthcare, social care, and voluntary sector professionals involved in an individual's care to promote a coordinated and person-centred approach. Support integrated care planning and case management initiatives that enable patients to manage their health and wellbeing effectively and reduce avoidable hospital admissions. Actively participate in practice-based MDT meetings and case discussions. Recognise situations requiring urgent intervention or escalation and promptly alert the appropriate healthcare professional or service. Foster effective communication between agencies to ensure seamless support for patients and carers.
Person Specification
Experience Essential
Own vechicle business use with UK driving licence Experience of working in a health, social care, community, voluntary sector, or customer service environment. Experience of supporting patients, service users, or members of the public to access services. Experience of managing competing priorities and working to deadlines and accurate record keeping. Knowledge of health and wellbeing services available within the local community. Excellent communication and interpersonal skills. Understanding of integrated care and multidisciplinary team working.
Desirable
Care Certificate. Knowledge of RiO, or similar clinical systems. Understanding of integrated care and multidisciplinary team working. Experience supporting people with long-term conditions, frailty, mental health needs, or complex care needs.
Education and Qualification Essential
oNationally recognised qualification in health, social care, counselling or other relevant professional or academic qualification oCommitment to/evidence of continuous professional development. oLevel of educational attainment to NVQ 3 / AS Level or equivalent
Desirable
Willingness to undertake further training relevant to and in line with the development of peer support role.
Skills and Aptitudes Essential
Computer literate, able to use email, the internet and web searches as standard applications and databases Excellent communication skills, both verbal and written; able to supply reports as required. Ability to collect data efficiently in order to provide statistical evidence for analysis
Desirable
Can demonstrate an approach to gaining knowledge of local services. Thorough and up-to-date knowledge and understanding of policy and practice in Adult Social Care and Health, including the principles of personalisation
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 Royal Free London NHS Foundation Trust
Address Lucas House
305-309 Fore Street
Edmonton
N9 0PZ
United Kingdom
Employer's website https://www.royalfreelondonjobs.co.uk/ (Opens in a new tab)