To undertake a focused person-centered approach, ensuring quality standard and delivery of care for patients. To develop safe clinical skills in the community setting to proactively manage very high-intensity users of health and social care services, with multiple co-morbidities and pharmacy, social, medical and nursing needs and who are at risk of hospital admission. To undertake nursing procedures as indicated for example, catheterisation, monitoring of vital signs and review of symptoms, and phlebotomy. To proactively monitor and manage a patient caseload with sound clinical autonomous decisions about patient care and seeking support from colleagues as appropriate. To confer, as appropriate and work with the patient's GP, BHC GP/Consultant, Directorate Lead Nurse, Clinical Lead, ANP, ACP and/or Out of Hours GPs to ensure there is robust communication around clinical issues as indicated. To sensitively deal with distressing or emotional circumstances regarding patient care, and communicate information, sensitively, requiring empathy and reassurance, to patients, and carers. To actively seek GP/Frailty Consultant to review polypharmacy and other medication issues in accordance with the Department of Health, Professional and organisational guidelines. To work effectively as part of a multidisciplinary team working to support the common goal of safe, efficient care delivery closer to the patients homes. To empower patients and their families through appropriate support and education. To utilise formal and informal reporting mechanisms, including electronic and handwritten reporting to ensure effective internal and external communications and to ensure all documentation is accurate and professional. Fully support the use of EMIS mobile and provide contemporaneous clinical records. To continuously challenge practice ensuring a sound evidence base thus meeting clinical governance requirements. Promote multidisciplinary teams working to provide rapid crisis intervention, the common goal of safe efficient care to people in their own homes. Support the Service Lead and Operational Leads in delivering the UCR KPIs and ensure that capacity is maintained, and timelines managed at times of escalation. To contribute to partnership working with Acute Trust GPs, Nursing/Residential home staff and other health care professionals within Bromley Healthcare, Social Services and voluntary agencies to promote an anticipatory care planning