Overview
An exciting opportunity has arisen to join the Homebound and Care Home Team in Five Towns PCN. PCNs are groups of GP practices working closely together to provide integrated services to the local population. The successful candidate will be joining an established PCN team made up of Care Coordinators, a Nurse Associate, registered Nurse and ANPs, focusing on the care of House bound and Care home residents. The team is under the direction of the PCN Business manager, 2 GP clinical leads and PCN Lead Nurse to deliver high quality services to housebound and hard to reach patients. This role will focus on supporting patients to be healthy, monitoring of long‑term conditions, health prevention and screening activities. They will work collaboratively with the Practice teams, as well as the wider PCN team, to meet the needs of patients and providing nurse leadership as required.
The role holder will be expected to work within the PCN/Primary Care as well as develop experience in a number of different settings such as care homes, long term care, palliative and end of life care, community, hospital or mental health services. The role holder understands the needs of a more diverse community/patient group(s) and prioritises patient needs within the scope of the role. The role holder is able to show a level of experience and ability to support patients, adapting communication, style and approach to meet the needs of a diversity of patient requirements and care needs with a track record of positive patient outcomes. Accesses advice and guidance from peers and supervisor on how to support patient requirement and care needs when faced with situations outside their scope of knowledge or practice. The role holder will draw on existing skills and experience in order to deliver a high quality service to the end user and clearly understands service user requirements, expectations and preferences. The role holder will understand the impact of potential decisions and evaluate risk of possible outcomes prior to taking actions, anticipating challenges which may need to be mitigated before they arise.
They will be required to manage patient/service user expectations, balancing different requirements to seek the optimum solution and ensure that relevant resources are in place to meet service user/patient/carer needs and work with others to achieve the outcomes required. The role holder will be required to work as part of the Practice’s multidisciplinary team, the post holder will effectively deliver nursing services to the entitled patient population. Provide routine nursing care to patients as required in accordance with clinical based evidence, NICE and the NSF. Prescribe medication for patients in accordance with PGDs and own scope of practice. Review patient medications to enhance compliance. Request pathology services, as necessary. Process pathology results, as required. Oversee the provision of chronic disease clinics, delivering patient care as necessary, referring patients to secondary/specialist care as required.
Maintain accurate clinical records in conjunction with extant legislation. Ensure effective use of read codes. Prioritise health issues and intervene appropriately. Support the Team in dealing with clinical emergencies. Recognise, assess and refer patients presenting with mental health needs. Implement vaccination programmes for adults. Support patients in the use of their prescribed medicines or over‑the‑counter medicines (within own scope of practice). Liaise with external services/agencies to ensure the patient is supported appropriately. Provide safe, evidence‑based, cost‑effective and individualised patient care across all patient groups within the PCN or GP Practice location. Support the delivery of preventative health programmes in line with NHS guidance. Support and/or undertake screening programmes in line with NHS guidance and protocols including vaccination clinics and new patient screening. Support the Advance Nurse Practitioner/Senior nurse to manage the care of patients with chronic illnesses e.g. Asthma, Diabetes, Coronary heart disease and hypertension ensuring continued maintenance of the relevant documentation/register. Undertake nursing treatment and procedures within your scope of practice for patients healthcare including ECG, cytology, weight management, lifestyle and health promotion, phlebotomy, routine immunisations and vaccinations. Be able to assess critically and re‑evaluate the clinical situation as the patient’s condition or needs changes ensuring clear communication with the patient, their carer/family.
Have direct responsibility for patient caseload, ensuring all patients have an accurate plan of care, which reflects the assessment undertaken and incorporate the issues and recommendations. Utilise evidence‑based practice and clinical audit to ensure appropriate assessment and management of patients within the primary care setting. Identify service improvement activity in liaison with the Multi‑Disciplinary Team and support the ANP or senior nurse in the review of policies and protocols. Highlight areas for training, audit and improvement. Complete clinical administration in support of core departmental and business activities including infection prevention and control. Work with the multi‑disciplinary primary healthcare team in order to support key outputs.
Qualifications and Experience
- Registered General Nurse
- Diplomas in chronic disease management (e.g. Diabetes, Asthma, COPD)
- Qualification in Non‑Medical Prescribing, Experience of working in a primary care setting
- Previous experience of working independently in the following areas: wound management, chronic disease management, vaccination clinics, anticipatory planning and end‑of‑life management
- Recognises when the limits of own competence are exceeded and is able to identify how and from whom to seek support
- Listens proactively and collaborates with colleagues and wider teams, and is able to share learning from their experiences
- Acts with integrity and professionalism at all times and is conscientious and committed to provide a high‑quality service
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