Occupational Therapist for Integrated Neighbourhood Team

• Undertaking comprehensive occupational therapy assessments in patients' homes, care homes and community settings.
• Assessing functional ability, cognition, mobility, activities of daily living, environmental risks and equipment needs.
• Developing, implementing and reviewing personalised intervention, rehabilitation and support plans.
• Recommending and facilitating appropriate equipment, adaptations and environmental modifications to support independence and safety.
• Supporting falls prevention, admission avoidance and timely hospital discharge pathways.
• Contributing to Comprehensive Geriatric Assessments (CGAs), personalised care planning and Electronic Treatment Escalation Plans (eTEPs).
• Working closely with GPs, nurses, pharmacists, social care colleagues, mental health professionals and wider multidisciplinary team members to coordinate care.
• Providing specialist occupational therapy advice to patients, carers, care home staff and other healthcare professionals.
• Maintaining accurate clinical records and ensuring safe, effective and evidence-based practice in line with HCPC and professional standards.
• Supporting service development, quality improvement initiatives, supervision of students or support staff and the continued development of neighbourhood-based frailty services.

• Manage a specialist caseload of patients with frailty, complex needs, long-term conditions and functional decline.
• Undertake comprehensive occupational therapy assessments within patients' homes, care homes and community settings.
• Assess functional ability, cognition, environmental factors, activities of daily living and psychosocial needs affecting independence and wellbeing.
• Develop and implement evidence-based intervention and rehabilitation programmes.
• Assess and recommend appropriate equipment, assistive technology, housing adaptations and environmental modifications.
• Support patients to maximise independence and safety in daily living activities.
• Develop comprehensive management and discharge plans that promote recovery, independence and quality of life.
• Undertake falls prevention assessments and interventions.
• Monitor progress and regularly review interventions to ensure optimal outcomes.
• Work within Mental Capacity Act legislation and gain valid consent for interventions.

• Support identification, assessment and prioritisation of patients within the Neighbourhood Frailty Programme.
• Contribute to Comprehensive Geriatric Assessments and holistic frailty reviews.
• Support the development of Personalised Care and Support Plans (PCSPs) and Electronic Treatment Escalation Plans (eTEPs).
• Contribute to proactive interventions aimed at preventing deterioration and reducing avoidable hospital admissions.
• Support safe and timely discharge from hospital and community rehabilitation pathways.
• Work proactively with care homes, domiciliary care providers and carers to optimise care delivery.

• Participate in Integrated Neighbourhood Team MDT meetings and case reviews.
• Work closely with GPs, ANPs, Paramedics, Community Nurses, Pharmacists, Social Workers, Mental Health Teams, Care Coordinators and VCSE partners.
• Coordinate rehabilitation and care plans across organisational boundaries.
• Provide specialist occupational therapy knowledge to complex clinical discussions and decision-making.

• Participate in service redesign and continuous improvement initiatives.
• Contribute to service evaluation, audit and outcome monitoring.
• Assist in the development of neighbourhood-based rehabilitation and frailty pathways.
• Support implementation of evidence-based practice and policy changes.

• Maintain accurate, timely and legally compliant patient records.
• Practice within HCPC standards and RCOT professional standards.
• Manage clinical risk within own caseload and working environment.
• Adhere to safeguarding, information governance, infection prevention and health and safety requirements.
• Maintain professional registration and actively participate in continuing professional development.

Essential

• Essential
• Degree or Diploma in Occupational Therapy.
• Current HCPC Registration as an Occupational Therapist.
• Evidence of post-registration training relevant to frailty, rehabilitation, older people's services or community practice.
• Evidence of ongoing CPD.

Desirable

• Desirable
• Postgraduate qualification to diploma level or equivalent experience.
• Master's level study in frailty, rehabilitation, occupational therapy or older people's care.
• Membership of the Royal College of Occupational Therapists (RCOT).

Essential

• Essential
• Community occupational therapy experience.
• Experience managing complex patients independently.
• Experience working within multidisciplinary teams.
• Experience undertaking home visits and lone working.
• Experience of functional assessment, intervention planning and discharge planning.

Desirable

• Experience working within frailty services.
• Experience working within an Integrated Neighbourhood Team, PCN or Community Rehabilitation Team.
• Experience of quality improvement, audit or service development.

Essential

• Full UK driving licence.
• Ability to travel independently across the Coastal locality.
• Ability to undertake home visits, lone working and community-based assessments.
• Enhanced DBS clearance.

Essential

• Patient-centred and compassionate approach.
• Excellent team-working skills.
• Professional and accountable practitioner.
• Resilient and adaptable.
• Reflective practitioner committed to lifelong learning.
• Committed to reducing health inequalities and improving outcomes for older people.

Essential

• Excellent occupational therapy assessment and clinical reasoning skills.
• Strong communication and interpersonal skills.
• Ability to work autonomously and prioritise workload effectively.
• Ability to communicate complex and sensitive information.
• Ability to manage risk in community and lone-working environments.
• Ability to teach, supervise and support others.
• Competent use of clinical IT systems and electronic patient records.

Essential

• Advanced occupational therapy assessment and intervention principles.
• Knowledge of frailty, falls prevention and rehabilitation.
• Understanding of integrated care and multidisciplinary team working.
• Knowledge of safeguarding and risk management.
• Understanding of the Mental Capacity Act and consent processes.
• Understanding of admission avoidance and discharge pathways.

Desirable

• Knowledge of eFI2 and frailty identification tools.
• Knowledge of local health, social care and voluntary sector services.
• Understanding of population health and anticipatory care models.