Community Integrated Team (CIT) Social Prescriber

Job Description

Post: Community Integrated Team (CIT) Social Prescriber

Contract Type: Permanent

Location: The City of Sunderland with an HQ at Age UK Sunderland (AUKS) Bradbury Centre,
Stockton Road
Responsible to:  Front Door Manager
Accountable to:  AUKS

The purpose of the Community Integrated Team (CIT) Social Prescribing Service is to put older
people in personal control of their health & wellbeing and provide them with integrated care and
support  in  their  local  community, focusing  on  prevention  of  ill  health  and  the  promotion  of
wellbeing.

The service enables older people to have improved health outcomes and independence whilst
reducing the burden on NHS services in Sunderland through the reduction in need for GP visits,
Out of Hours Contacts, emergency admissions/readmissions etc.

Key working Relationships:
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Statutory and Community based providers
Integrated Care Teams
Older people aged 65+
Carers and Carer Organisations
Other clinical and non-traditional provider groups as required

Purpose of the post:
The  post  provides  an  interface  between  voluntary  sector  provider  organisations  and  service
users, health and  social care multi-disciplinary  teams  (MDT) and  other statutory  bodies. The
social prescriber will support individuals to self-manage their needs.  The post holder will work in
a designated Sunderland locality visiting older people in their homes as well as other community
settings.  Many  older  people  will  have  complex  health  needs  and  the  service  will  focus  on
practical support to encourage the utilisation of services within the local communities.

This may include:

  Assisted  signposting  to  services  in  the  community  that  help  maintain  older  people’s

health & wellbeing such as leisure & learning, social groups etc.

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  One  to  One  Support  to  help  with  issues  such  as  arranging  for  support  to  access
appointments, travel, access to community care assessments (or carers assessments),
where appropriate advise on main choices regarding personal budgets and helping with
domestic support etc.

  Social Contact to establish support from befriending services for those in social isolation

or risk of and make referrals to appropriate internal and partner services

  Interim support to help support the older person whilst other support  is put in place

The post holder will also identify unpaid carers and enable access to appropriate services.

Key Responsibilities

The post holder will be an excellent communicator and develop a wide knowledge of the services
offered by non-traditional providers. The post holder will require strong organisation skills, must
be flexible in approach, able to exercise initiative and demonstrate a consistently high standard
of professionalism, being aware of the need for confidentiality and integrity.

Tasks:

  Liaison with Community Integrated Locality Teams
  Assessments & home visits
  GP & professional liaison
  Patient information gathering & analysis to provide a holistic plan of support (social,

financial, health & wellbeing etc.)

  In depth knowledge gathering on available services (community & statutory), multi-

disciplinary services etc.

  Publicity & promotion of offering
  Record keeping, monitoring & evaluation
  Identification of step up care and safeguarding
  Identification of gaps in services to inform future development

Key skills
Integrated Care Coordination

  Signposting older people to the multitude of support  services that are available through

voluntary and statutory providers tailored to the person’s specific needs

  Be  the  point  of  liaison  for  service  users  and  carers  principally  with  voluntary  sector
providers  as  well  as  useful  commercial  services,  and  liaising  with  other  statutory
professionals involved in patient’s care

  Delivering case work to support older people to reach specific goals in accordance with

KPIs

  Promote the independence & empowerment of older people
  Build strong relationships with partners and providers
  Deal in a professional, helpful & sensitive manner with older people, staff, carers & other

agencies.

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Information and Data Coordination

  To be proficient  in  using Microsoft office packages and  other  identified IT  systems and

support other team members in their use

  To record relevant patient documentation on identified IT systems as required in line with

GDPR requirements

  Facility for learning new software packages which may be in continued development
  Maintain Excel, Charity Log and other databases to input patients’ engagement
  Support  completion  of  patient  referrals,  record  electronically  and  feedback  to  team

members

  Input data onto the patient information management systems to update patient details, and

periodically use reports to ensure patient details are correct

  Extract caseload information from the patient database as required for reporting purposes
  Be responsible for updating the electronic service directory on a regular basis, sourcing

referral criteria and ensuring these are accessible to all relevant parties

Patient Support

  Ensure older people’s requirements are managed smoothly with no fragmentation in

service delivery.

  Ensure  appropriate  actions

from  Multi-Disciplinary  Team  (MDT)/Integrated

team

meetings are completed in a timely fashion.

  Communicate with members of the MDT/Integrated teams as required.
  Communicate  effectively  with  older  people  and  their  families/carers,  other  staff  both

internal and external and members of the public.

General

  The post holder must at all times carry out duties and responsibilities with due regard to

the organisations’ equal opportunity policies and procedures.

  The  post  holder  must  at  all  times  respect  patient  confidentiality  and,  in  particular,  the
confidentiality  of  electronically  stored  personal  data  in  line  with  the  requirements  of
GDPR/Data Protection Act.

  The post holder is expected to take responsibility for self-development on a continuous

basis, undertaking on-the-job training as required.

  The post holder must be aware of individual responsibilities under the Health and Safety
at  Work  Act,  and  identify  and  report  as  necessary  any  untoward  accident  incident  or
potentially hazardous environment.

  The post holder will ensure they accurately represent Age UK Sunderland  and ensure the

values of Age UK Sunderland are upheld at all times in carrying out their work

  The post holder must act as a Safeguarding alerter in line with AUKS policy
  The  post  holder  must  work  in  general  accordance  with  the  organisation’s  policies  and

guidelines at all times..

This job description is intended as a guide to the main responsibilities of the post and not as an
exhaustive list of duties and tasks. The post holder may be required to undertake other duties
appropriate to his/her grade, which are not listed above, at the direction of AUKS Chief Executive
Officer. The  job description may be amended from time to time after consultation with the post
holder.

This post is subject to a Disclosure & Barring Service (DBS) Enhanced check.

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Person Specification

Post: Community Integrated Team (CIT) Social prescriber

Location: The City of Sunderland with an HQ at Age UK Sunderland (AUKS) Bradbury Centre,
Stockton Road
Responsible to: Front Door Manager
Accountable to: AUKS

Essential Criteria

  NVQ Level 3 in health, social care or equivalent
  At least 2 years’ experience in health/social care or information & advice or work in direct

contact with people, families & carers (paid or voluntary capacity)
IT competence and experience of Microsoft packages and admin skills

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  Proven record of written and verbal communication skills
  Able to deal sensitively with patients
  Able to work as part of a team
  Able to prioritise and manage own workload
  Analytical skills and be able to interpret information and data and present it in a clear

concise manner

  Good people skills with a friendly approachable style and ability to generate trust and

form positive relationships

  A good listener
  Flexible & responsive to changing needs of clients
  Ability to communicate and extract information sensitively & tactfully
  Creative approach to problem solving
  Tactful and diplomatic, able to build a rapport with people from a wide range of

backgrounds

  Experience in use of databases
  Experience of working in a voluntary, NHS or social care setting delivering services to

vulnerable people

  Experience of risk assessment & risk management
  Knowledge of voluntary care organisations (preferably within the Sunderland area)
  Understanding of patient confidentiality
  Understanding of health and social care processes
  Understanding of the complexity of older people’s lives & the barriers they face
  Understanding of safeguarding responsibilities
  Knowledge of the range of voluntary, statutory and private sector orgs/services working

with older people

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  Understanding of welfare benefits available to older people

  Knowledge of GDPR

  Willingness to undergo further training or development

  To abide by and implement all policies and procedures of Age UK Sunderland, including
being  aware  of  and  responsible  corporately  and  as  an  individual  for  Health  and  Safety
policy.

  Possess a full clean driving licence and have access to a car for work

Desirable

  Experience in motivational interviewing

  Experience of person centred planning

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