Where does the ‘buck stop’ when the CCN hands over responsibility to unqualified carers? Mark Whiting, Consultant Nurse, Children with complex health needs

Where does the ‘buck stop’ Where does the ‘buck stop’ when the CCN hands over when the CCN hands over responsibility to unqualified responsibility to unqualified

carers?carers?

Mark Whiting, Mark Whiting, Consultant Nurse,Consultant Nurse,

Children with complex health needsChildren with complex health needsWest Hertfordshire Primary Care TrustWest Hertfordshire Primary Care Trust

Who are these carers?Who are these carers?

Band 3 health care support workers Band 3 health care support workers employed by your own Trustemployed by your own Trust

Band 4 assistant practitioners employed Band 4 assistant practitioners employed by your own Trustby your own Trust

Learning Support Assistants (LSAs and Learning Support Assistants (LSAs and Mealtime Support Assistants employed by Mealtime Support Assistants employed by the Local Education Authority and working the Local Education Authority and working in school)in school)

Who are these carers?Who are these carers?

Care workers based in Local Authority children’s Care workers based in Local Authority children’s homes and respite care facilitieshomes and respite care facilities

Transport staff employed or contracted by the Transport staff employed or contracted by the Local Authority to accompany children in transit Local Authority to accompany children in transit from home to schoolfrom home to school

““Shared carers”.Shared carers”. Care staff employed by ‘3Care staff employed by ‘3rdrd Sector’ providers Sector’ providers

such as Mencap, NCH, Barnardo’ssuch as Mencap, NCH, Barnardo’s Individuals employed by parents on a Direct Individuals employed by parents on a Direct

Payments basis.Payments basis.

If you weren’t If you weren’t concerned before I concerned before I

started you might be started you might be now!now!

Administering prescribed medicine in pre-measured dose Administering prescribed medicine in pre-measured dose via naso-gastric tube or gastrostomy tubevia naso-gastric tube or gastrostomy tube

Bolus or continuous feeds via a naso-gastric or Bolus or continuous feeds via a naso-gastric or gastrostomy tubegastrostomy tube

Tracheostomy care including suction and emergency Tracheostomy care including suction and emergency change of tracheostomy tubechange of tracheostomy tube

Injections (intra-muscular or subcutaneous) with pre-Injections (intra-muscular or subcutaneous) with pre-loaded syringeloaded syringe

Intermittent catheterisation and catheter careIntermittent catheterisation and catheter care Care of a MitrofanoffCare of a Mitrofanoff Stoma careStoma care

What sort of things might you be What sort of things might you be teaching? (RCN 2005)teaching? (RCN 2005)

Inserting suppositories or pessaries with a pre-Inserting suppositories or pessaries with a pre-packaged dose of a prescribed medicinepackaged dose of a prescribed medicine

Rectal medication with a pre-packaged doseRectal medication with a pre-packaged dose Administration of buccal or intra-nasal MidazolamAdministration of buccal or intra-nasal Midazolam Emergency treatments covered in basic first aid Emergency treatments covered in basic first aid

trainingtraining Assistance with inhalers, insufflation cartridges and Assistance with inhalers, insufflation cartridges and

nebulisersnebulisers Assistance with oxygen administrationAssistance with oxygen administration Basic life support/resuscitationBasic life support/resuscitation

What sort of things might you be What sort of things might you be teaching? (RCN 2005)teaching? (RCN 2005)

And perhaps you shouldn’t be teachingAnd perhaps you shouldn’t be teaching

Re-insertion of naso-Re-insertion of naso-gastric tubegastric tube

Re-insertion of Re-insertion of gastrostomy tubegastrostomy tube

Injections involving:Injections involving: assembling syringe,assembling syringe, administering administering

intravenouslyintravenously controlled drugs.controlled drugs.

Programming of Programming of syringe driverssyringe drivers

Filling of oxygen Filling of oxygen cylinderscylinders

Are you Are you worried yet?worried yet?

Levels of teachingLevels of teaching

General observationGeneral observation – to reduce anxiety – to reduce anxiety – the staff being taught are not expected – the staff being taught are not expected to carry out the procedureto carry out the procedure

Certificate of attendance – Certificate of attendance – you may be you may be expected to sign and confirm the nature of expected to sign and confirm the nature of the teaching and which individual staff the teaching and which individual staff members were presentmembers were present


Statement of competenceStatement of competence If you are delegating care to another If you are delegating care to another

unqualified person you may be asked to unqualified person you may be asked to provide formal confirmation that you provide formal confirmation that you consider the person to be competent to consider the person to be competent to undertake that care.undertake that care.

If you are signing to confirm that a carer is If you are signing to confirm that a carer is competent to undertake a particular procedure competent to undertake a particular procedure you need to be confident that they are!you need to be confident that they are!• Teaching/LearningTeaching/Learning• Observation of competenceObservation of competence• Assessment of knowledge/skillsAssessment of knowledge/skills


The carer should also sign to confirm that The carer should also sign to confirm that they are accepting responsibility for the care they are accepting responsibility for the care which you are which you are de factode facto delegating to them delegating to them

You should set and record an ‘expiry date’ for You should set and record an ‘expiry date’ for that competencethat competence

Make your own written (signed and dated) Make your own written (signed and dated) records and ensure that you have also records and ensure that you have also provided clear written protocols/guidance.provided clear written protocols/guidance.

Parents (and the child if appropriate) should Parents (and the child if appropriate) should be as fully involved in the whole process as be as fully involved in the whole process as possiblepossible

Accountability IAccountability I

““You may be expected to delegate care delivery You may be expected to delegate care delivery to others who are not registered nurses or to others who are not registered nurses or midwives. Such delegation must not midwives. Such delegation must not compromise existing care but must be directed to compromise existing care but must be directed to meeting the needs of and serving the interests of meeting the needs of and serving the interests of patients and clients. You remain accountable for patients and clients. You remain accountable for the appropriateness of the delegation and for the appropriateness of the delegation and for ensuring the person who does the work is able to ensuring the person who does the work is able to do it and that adequate supervision and support do it and that adequate supervision and support is provided”. (Paragraph 4.6)is provided”. (Paragraph 4.6)

Nursing and Midwifery Council, 2002 Nursing and Midwifery Council, 2002 The NMC code of The NMC code of professional conduct: standards for conduct, performance professional conduct: standards for conduct, performance and ethics. London, NMC. (and NMC, 2007, Advice on and ethics. London, NMC. (and NMC, 2007, Advice on Delegation for NMC Registrants. London, NMC.)Delegation for NMC Registrants. London, NMC.)

Accountability IIAccountability II

““If a health professional were to give If a health professional were to give negligent advice to a patient or to the carers negligent advice to a patient or to the carers and, in reliance on that advice, harm was and, in reliance on that advice, harm was caused, then, if the advice was given knowing caused, then, if the advice was given knowing that it would be relied upon, the heath that it would be relied upon, the heath professional or employer could be held professional or employer could be held accountable” accountable” (Page 140)(Page 140)

Dimond B (2005) Dimond B (2005) Legal aspects of the community care of the sick Legal aspects of the community care of the sick childchild. In Sidey A, & Widdas D (eds) . In Sidey A, & Widdas D (eds) Textbook of Community Textbook of Community Children’s Nursing (2Children’s Nursing (2ndnd edn edn) Edinburgh, Elsevier.) Edinburgh, Elsevier.

And who is doing the teaching?And who is doing the teaching?

The Nurse Consultant?The Nurse Consultant? The Community Matron?The Community Matron? The Team Leader?The Team Leader? The Band 6 nurse?The Band 6 nurse? The Band 5 nurse?The Band 5 nurse?

Skill-mix and grade-mix Skill-mix and grade-mix in CCN servicesin CCN services

Grade mix and skill mixGrade mix and skill mix

Grade mixGrade mix ““A team of nurses who A team of nurses who

are paid on different are paid on different salary scales (grades salary scales (grades or bands) and whose or bands) and whose levelslevels of responsibility of responsibility are determined by the are determined by the grade which is grade which is attached to the post attached to the post which they hold”which they hold”

Skill mixSkill mix ““A team of nurses A team of nurses

within which the total within which the total range of skills which range of skills which the team provide is the team provide is determined in a determined in a systematic way in systematic way in response to the needs response to the needs of the population to be of the population to be served and the served and the services to be services to be delivered to them”delivered to them”

““Community Paediatric Nursing Community Paediatric Nursing in England in 1988”in England in 1988”

45 CCNs in the whole of England45 CCNs in the whole of England 40 employed at “Sister/Charge Nurse” grade40 employed at “Sister/Charge Nurse” grade 4 employed as “Staff Nurse grade4 employed as “Staff Nurse grade 1 District Enrolled Nurse1 District Enrolled Nurse

44 Registered Sick Children’s Nurses44 Registered Sick Children’s Nurses 1 Enrolled Nurse1 Enrolled Nurse

23 also qualified as RGN23 also qualified as RGN 22 qualified as District Nurse22 qualified as District Nurse 2 qualified as Health Visitors2 qualified as Health Visitors 1 qualified as both DN and HV1 qualified as both DN and HV (Only two held Degree qualifications)(Only two held Degree qualifications)


23 CCN teams in the whole of England23 CCN teams in the whole of England 11 teams made up of one CCN only11 teams made up of one CCN only 5 teams of two CCNs5 teams of two CCNs 5 teams of three CCNs5 teams of three CCNs One team of four CCNsOne team of four CCNs One team of five CCNs (plus 1 x diabetes One team of five CCNs (plus 1 x diabetes

liaison nurse plus 1 x special school sister)liaison nurse plus 1 x special school sister)


23 CCN teams23 CCN teams 12 teams working 9-5 Monday to Friday12 teams working 9-5 Monday to Friday 8 teams working 9-5 7 days per week8 teams working 9-5 7 days per week 2 teams providing 24/7 cover2 teams providing 24/7 cover 1 team working alternate weekends1 team working alternate weekends


23 CCN teams23 CCN teams 23 teams caring for children with chronic 23 teams caring for children with chronic

diseasedisease 23 teams caring for children with acute 23 teams caring for children with acute

‘medical’ problems‘medical’ problems 19 teams following up non-day case surgical 19 teams following up non-day case surgical

patientpatient 18 teams providing care to children with 18 teams providing care to children with

disabilities disabilities 11 teams providing day-case follow-up11 teams providing day-case follow-up

““Community Paediatric Nursing Community Paediatric Nursing in England in 1988”in England in 1988”Range of medical problemsRange of medical problems No of teamsNo of teams

Respiratory conditions – such as asthmaRespiratory conditions – such as asthma 2020

Tracheostomy/stoma careTracheostomy/stoma care 1818

Cancer/leukaemiaCancer/leukaemia 1717

Congenital orthopaedic problemsCongenital orthopaedic problems 1717

Eczema/skin disordersEczema/skin disorders 1515

Enuresis/encopresisEnuresis/encopresis 1515

Congenital cardiac diseaseCongenital cardiac disease 1515

Acute medical problems e.g. gastro-enteritisAcute medical problems e.g. gastro-enteritis 1515

DiabetesDiabetes 1414

Renal problems e.g. nephrotic syndromeRenal problems e.g. nephrotic syndrome 1010

Blood dyscrasias – haemophilia/sickle cell etc.Blood dyscrasias – haemophilia/sickle cell etc. 99

Constipation Constipation 55

Cystic fibrosisCystic fibrosis 33


Nursing care activitiesNursing care activities No of teamsNo of teams

Teaching practical care procedures to parentsTeaching practical care procedures to parents 2323

Supporting families of dying childrenSupporting families of dying children 2222

Teaching other professionals/colleaguesTeaching other professionals/colleagues 2222

Education of parents and children re medical problemsEducation of parents and children re medical problems 2222

Post-operative wound carePost-operative wound care 1919

‘‘General’ health educationGeneral’ health education 1919

Administration/supervision of medication (not IV)Administration/supervision of medication (not IV) 1919

Dressings/wound care following trauma: cuts/scalds etc.Dressings/wound care following trauma: cuts/scalds etc. 1818

Administration of IV drugsAdministration of IV drugs 1212

Pre-operative work-up/preparationPre-operative work-up/preparation 22

Care of ventilated children at homeCare of ventilated children at home 22


Experience and qualifications required to be a Experience and qualifications required to be a “Community Paediatric Nurse”?“Community Paediatric Nurse”?

QualificationsQualifications RSCN - 21 out of 23RSCN - 21 out of 23 DN certDN cert - 10 out of 23- 10 out of 23 DN or HV – 1 out of 23DN or HV – 1 out of 23

ExperienceExperience Paediatrics – 15 out of 23Paediatrics – 15 out of 23 Counselling – 5 out of 23Counselling – 5 out of 23 Community – 3 out of 23Community – 3 out of 23

““Wise decisions – developing Wise decisions – developing paediatric homecare teams” (RCN paediatric homecare teams” (RCN

1994)1994) Identified a number of areas of practice where Identified a number of areas of practice where

paediatric home care was becoming importantpaediatric home care was becoming important Cancer and leukaemiaCancer and leukaemia Cystic fibrosisCystic fibrosis The sick neonateThe sick neonate AsthmaAsthma DiabetesDiabetes Day admissionsDay admissions Respite careRespite care General nursing care at homeGeneral nursing care at home

Qualifications and experienceQualifications and experience Grade EGrade E

RSCN/Child branchRSCN/Child branch Minimum 1 year hospital Minimum 1 year hospital

paediatric experiencepaediatric experience

Grade G: (as F plus)Grade G: (as F plus) Community qualification essentialCommunity qualification essential CCN experience essentialCCN experience essential Specialist interest with appropriate Specialist interest with appropriate

qualification desirablequalification desirable Teaching and assessing (ENB 998) Teaching and assessing (ENB 998)

desirabledesirable First degree desirableFirst degree desirable

Grade H: (as G plus)Grade H: (as G plus) Previous experience at G grade or Previous experience at G grade or

equivalent essential equivalent essential Training in management skills Training in management skills

essentialessential Training as a community practice Training as a community practice

teacher desirableteacher desirable

Grade F: (as E plus)Grade F: (as E plus) Community qualification Community qualification

desirabledesirable Further paediatric Further paediatric

experience – hospital or experience – hospital or communitycommunity

Commitment to formal Commitment to formal academic development academic development desirabledesirable

Additional featuresAdditional features Grade EGrade E

Should not make initial visits Should not make initial visits unaccompaniedunaccompanied

No independent responsibility No independent responsibility for overall care of individual for overall care of individual patientspatients

Grade GGrade G Possible areas of specialist clinical Possible areas of specialist clinical

knowledge with ability to lead the knowledge with ability to lead the team in these areas.team in these areas.

Mentor/assessor/supervisor of pre Mentor/assessor/supervisor of pre and post- Registration student and post- Registration student nurses nurses

Grade HGrade H Leads team in all aspects of clinical Leads team in all aspects of clinical

practicepractice Overall responsibility for team Overall responsibility for team

caseloadcaseload Leads policy developmentLeads policy development Managers pay and non-pay budgetsManagers pay and non-pay budgets

Grade F Grade F ““Higher level” of clinical Higher level” of clinical

skills and knowledgeskills and knowledge Independent responsibility Independent responsibility

for overall care of for overall care of individual patients but with individual patients but with day-to-day senior support day-to-day senior support to take on responsibility for to take on responsibility for care of groups of patientscare of groups of patients

1994-20041994-2004

Major expansion in CCN services Major expansion in CCN services provisionprovision

Growing range of specialist CCN services Growing range of specialist CCN services being provided in the communitybeing provided in the community

Shift in services from hospital to homeShift in services from hospital to home Introduction of Specialist Practitioner Introduction of Specialist Practitioner

Qualification in Community Children’s Qualification in Community Children’s NursingNursing

Expansion in CCN Services Expansion in CCN Services ProvisionProvision

020406080

100120140160180200

1954 1959 1964 1969 1974 1984 1989 1994 1999 2004

No of teams

Growing range of specialist CCN services Growing range of specialist CCN services being provided in the communitybeing provided in the community

Community Children’s Nursing is now an Community Children’s Nursing is now an ‘umbrella’ term which may be applied to a ‘umbrella’ term which may be applied to a wide range of roles and areas of specialist wide range of roles and areas of specialist practice including:practice including: ‘‘Traditional’ community children’s nursingTraditional’ community children’s nursing Disability NursingDisability Nursing Special School NursingSpecial School Nursing Palliative CarePalliative Care Diabetes CareDiabetes Care Respiratory CareRespiratory Care OncologyOncology Continuing CareContinuing Care Advanced PracticeAdvanced Practice

Shift in services from hospital to Shift in services from hospital to homehome

““Shifting the balance of care”Shifting the balance of care” ““Care closer to home”Care closer to home” ““Hospital-at-home”Hospital-at-home” ““Intermediate care”Intermediate care” ““Ambulatory care”Ambulatory care” ““Long term conditions care”Long term conditions care” ““Modelling the future”Modelling the future” Darzi review “ Our NHS: Our future”Darzi review “ Our NHS: Our future”

Specialist Practitioner Specialist Practitioner Qualification in Community Qualification in Community

Children’s NursingChildren’s Nursing Introduced in 1996, the course rapidly Introduced in 1996, the course rapidly

became established in all four UK became established in all four UK countriescountries First intakes tended to be experienced CCNs First intakes tended to be experienced CCNs

seeking to consolidate their experience seeking to consolidate their experience through formal academic studythrough formal academic study

In more recent years, an increasing proportion In more recent years, an increasing proportion of students were relatively new to the of students were relatively new to the community, some even gained sponsorship community, some even gained sponsorship from hospital based posts.from hospital based posts.

Specialist Practitioner Specialist Practitioner Qualification in Community Qualification in Community

Children’s NursingChildren’s Nursing Arguably course had a limited appeal for CCNs Arguably course had a limited appeal for CCNs

in specialist roles. Curriculum was relatively in specialist roles. Curriculum was relatively inflexible as UKCC (then NMC) regulations inflexible as UKCC (then NMC) regulations placed significant restrictions on many aspects placed significant restrictions on many aspects of programme design.of programme design.

Latterly, uncertainty over training monies, lack of Latterly, uncertainty over training monies, lack of explicit support/direction from NMC and inertia explicit support/direction from NMC and inertia arising from DOH Modernising Nursing Careers arising from DOH Modernising Nursing Careers have seen a significant reduction in HEIs have seen a significant reduction in HEIs offering the programme and students coming offering the programme and students coming forward for the programme.forward for the programme.

0

20

40

60

80

New Registrations of CCNs per year 1997-2006(Data supplied by NMC)

CCNsregistered inthe year

And then came… And then came…

AGENDA AGENDA FOR FOR

CHANGECHANGE

Band 5Band 5 Grade D and Grade E (roughly)Grade D and Grade E (roughly)

Entry level to qualified nursing practice in CCN team Entry level to qualified nursing practice in CCN team RCN Band 5 Community staff nurse profileRCN Band 5 Community staff nurse profile

• Assesses patients, plans, implements care in the community, Assesses patients, plans, implements care in the community, provides advice; maintains associated recordsprovides advice; maintains associated records

• Carries out nursing proceduresCarries out nursing procedures• May provide clinical supervision to other staff, studentsMay provide clinical supervision to other staff, students

Is it appropriate to appoint to a CCN post Is it appropriate to appoint to a CCN post immediately upon registration or is some prior immediately upon registration or is some prior experience in hospital essential?experience in hospital essential?

Is it possible in small CCN teams to provide Is it possible in small CCN teams to provide appropriate mentorship/preceptorship/support?appropriate mentorship/preceptorship/support?

Band 6Band 6

Band E and F (roughly)Band E and F (roughly) From RCN Band 6 District Nursing Sister profileFrom RCN Band 6 District Nursing Sister profile

Assesses patients, plans & implements care in the Assesses patients, plans & implements care in the community; provides advice to patients/clients; community; provides advice to patients/clients; maintains associated recordsmaintains associated records

Carries out nursing proceduresCarries out nursing procedures Co-ordinates nursing team workloadsCo-ordinates nursing team workloads

Should there be a requirement that Band 6 Should there be a requirement that Band 6 nurses hold a CCN qualification?nurses hold a CCN qualification?

Band 7Band 7

Band G and H (roughly)Band G and H (roughly) From RCN Band 7 District Nursing Sister (Team From RCN Band 7 District Nursing Sister (Team

Manager) profile:Manager) profile: Manages team of community nurse specialists and Manages team of community nurse specialists and

other staff covering a geographical area, including other staff covering a geographical area, including recruitment, appraisalrecruitment, appraisal

Assesses patients, plans & implements care; Assesses patients, plans & implements care; maintains associated recordsmaintains associated records

Carries out nursing proceduresCarries out nursing procedures Or is this the level at which CCN qualification Or is this the level at which CCN qualification

should be an essential requirement for the job?should be an essential requirement for the job?

Band 8Band 8 Band H and I (roughly)Band H and I (roughly) From RCN Band 8 Community Matron profile:From RCN Band 8 Community Matron profile:

Manages and provides leadership for managers, Manages and provides leadership for managers, specialist nurses/midwives and other staff in a primary specialist nurses/midwives and other staff in a primary care settingcare setting

Ensures patient/client/carer involvement in Ensures patient/client/carer involvement in development of services and promotes better health, development of services and promotes better health, social care and medicines managementsocial care and medicines management

Provides specialist education and training to other Provides specialist education and training to other staffstaff

Maintains compliance with, and development of, Maintains compliance with, and development of, policies, procedures and guidelines, including case policies, procedures and guidelines, including case management; co-ordinates care in a community management; co-ordinates care in a community settingsetting

Modernising Nursing Careers Modernising Nursing Careers (DoH, 2006)(DoH, 2006)

The nursing workforce will need to “work in a range The nursing workforce will need to “work in a range of settings, crossing hospital and community of settings, crossing hospital and community care…”care…”

Nurses will “start their careers in the community”Nurses will “start their careers in the community”

There will be “many opportunities for nurses in acute There will be “many opportunities for nurses in acute settings to work wholly or partially outside hospital.”settings to work wholly or partially outside hospital.”

““We also need to address current inflexibilities and We also need to address current inflexibilities and barriers in nursing…these currently exist between barriers in nursing…these currently exist between the branches……”the branches……”

““The health departments will work with key The health departments will work with key stakeholders to review the career pathways and stakeholders to review the career pathways and education preparation required for nursing in the education preparation required for nursing in the community”community”

Towards a framework for post-Towards a framework for post-Registration nursing careers (DoH 2007)Registration nursing careers (DoH 2007)

Careers in the five care pathwaysCareers in the five care pathways

The Children, Public and Family Health Pathway The Children, Public and Family Health Pathway will will help build dedicated public health capacity and capability help build dedicated public health capacity and capability into the system. The emphasis will be on intervening at a into the system. The emphasis will be on intervening at a population level and in working in partnership to address population level and in working in partnership to address the determinants of health. Health needs assessment for the determinants of health. Health needs assessment for populations, communities, groups, families and populations, communities, groups, families and individuals will be a key component and will provide the individuals will be a key component and will provide the basis for intervention to improve health, reduce health basis for intervention to improve health, reduce health inequalities and support for vulnerable families and inequalities and support for vulnerable families and individuals. This pathway will also encompass the individuals. This pathway will also encompass the maintenance and improvement of children and young maintenance and improvement of children and young people’s health within a philosophy of family centred care people’s health within a philosophy of family centred care in a range of settings.in a range of settings.

Community and Primary Care NursingCommunity and Primary Care Nursing

There is likely to be a greater impact on There is likely to be a greater impact on community and primary care nurses whose community and primary care nurses whose careers are built on and loosely organised careers are built on and loosely organised around adult nursing, services for children and around adult nursing, services for children and families and nursing in general practice.families and nursing in general practice.

The future of the specialist community and The future of the specialist community and public health practitioner qualification also needs public health practitioner qualification also needs to be considered, which has provided a to be considered, which has provided a benchmark of competency for some nurses benchmark of competency for some nurses working in primary and community care.working in primary and community care.

Grade mix and skill mixGrade mix and skill mix

Grade mixGrade mix ““A team of nurses who A team of nurses who

are paid on different are paid on different salary scales (grades salary scales (grades or bands) and whose or bands) and whose levelslevels of responsibility of responsibility are determined by the are determined by the grade which is grade which is attached to the post attached to the post which they hold”which they hold”

Skill mixSkill mix ““A team of nurses A team of nurses

within which the total within which the total range of skills which range of skills which the team provide is the team provide is determined in a determined in a systematic way in systematic way in response to the needs response to the needs of the population to be of the population to be served and the served and the services to be services to be delivered to them”delivered to them”

So for a child population of So for a child population of 50,00050,000

Grade mixGrade mix 1 x Band 8 Modern 1 x Band 8 Modern

MatronMatron 2 x Band 7 Team Leaders2 x Band 7 Team Leaders 1 x Band 6 Senior Staff 1 x Band 6 Senior Staff

Nurse/Junior SisterNurse/Junior Sister 3 x Band 5 Junior Staff 3 x Band 5 Junior Staff

NursesNurses

Skill mixSkill mix Range of specialist clinical Range of specialist clinical

knowledge and skills knowledge and skills including oncology, including oncology, diabetes, respiratory care diabetes, respiratory care etcetc

Broad range of advanced Broad range of advanced practice skills – practice skills – Assessment, Diagnosis and Assessment, Diagnosis and Treatment, Non- medical Treatment, Non- medical prescribing, Nurse- lead prescribing, Nurse- lead clinicsclinics

Providing a service 7 days Providing a service 7 days per week from 8 am to 8 pmper week from 8 am to 8 pm

Commitment to CPD, Commitment to CPD, teaching, preceptorship and teaching, preceptorship and researchresearch

Documents

Where does the ‘buck stop’ when the CCN hands over responsibility to unqualified carers? Mark Whiting, Consultant Nurse, Children with complex health needs