NHS Newcastle Upon Tyne, England, United Kingdom
Job Summary
The specific purpose of the post is to support and improve the health and wellbeing of frail, housebound patients. The role will focus on long‑term medical conditions such as diabetes, hypertension, and cardiovascular disease, while also taking a holistic view, including providing information, advice, or referrals to other services.
The post holder will work within a PCN frailty team including a health care assistant (HCA), social prescriber (SPLW) and a GP frailty lead, liaising closely with clinicians at each of the practices within the OW Primary Care Network (PCN) and other members of the broader PCN team.
The clinical part of the role will primarily involve visiting patients in their own home, using a person‑centred approach to undertake a comprehensive needs assessment, taking a detailed history and formulating a simple management plan based on this information together with the results of simple investigations (e.g. blood pressure and blood results) performed by the HCA. Management will follow protocols and medical guidelines for the relevant conditions and be guided by GP input when required.
The role does NOT involve the assessment and management of acutely unwell patients.
Core Responsibilities
* Visit patients at home as part of the OW PCN frailty team.
* Make a comprehensive holistic assessment of health and wellbeing needs, including history taking and simple investigations.
* Recognise situations that may be detrimental to the health and well‑being of the individual and act on the findings.
* Provide ongoing management of long‑term conditions such as diabetes, COPD, hypertension, and cardiovascular disease.
* Support and advise patients on the promotion of health, prevention of ill‑health, and the self‑management of their health within their own abilities.
* Undertake comprehensive care planning including Emergency Health Care Planning (EHCP).
* Provide general and specific health screenings to the patients with referral to GPs as necessary.
* Ensure proactive and early case management of frail patients with complex needs to prevent unnecessary hospital admissions/readmissions.
* Maintain effective communication with GP practice and other appropriate healthcare teams to the benefit of the patient.
* Support the HCA and SPLW, providing guidance when necessary.
Secondary Responsibilities
* Participate in audit work, effectively utilising the audit cycle.
* Participate in local initiatives to enhance service delivery and patient care.
* Support and participate in shared learning within the practice.
* Continually review clinical practices, responding to local and national policies and initiatives where appropriate.
* Participate in the review of significant and near‑miss events applying a structured approach, i.e. root cause analysis.
Qualifications – Essential
* Registered Nurse.
* Experience of working in a primary care environment.
* Experience of working as a practice nurse or community nurse.
* Experience of chronic disease management.
* Excellent communication skills (written and oral).
* Strong IT skills.
* Clear, polite telephone manner.
* Competent in the use of Office and Outlook.
* EMIS and S1 user skills.
* Effective time management (planning and organising).
* Ability to work as a team member and autonomously.
* Good interpersonal skills.
* Problem solving and analytical skills.
* Ability to follow clinical policy and procedure.
* Experience with audits.
* Experience with clinical risk management.
Qualifications – Desirable
* Post graduate diploma or degree (primary care).
* Independent prescriber.
* Experience of working within a Primary Care Network or multi‑site context.
* Knowledge of public health issues in the local area.
* Awareness of issues within the wider health arena.
Recruitment and Registration Information
* This post is subject to the Rehabilitation of Offenders Act (Exceptions Order) 1975 and will require a Disclosure and Barring Service check.
* Applicants must have current UK professional registration.
Employer: Denton Park Medical Group
Address: Denton Park Health Centre, West Denton Way, Newcastle Upon Tyne, NE5 2QW
Website: https://www.dentonparkmedicalgroup.co.uk
#J-18808-Ljbffr