The Ageing Well Nurse will work within their professional scope of practice in a general practice environment as part of our Primary Care Network (PCN). The PCN is made up of 5 member Practices and serves approximately 69,000 patients.
As a key member of a multidisciplinary team, they will play a key role in preventing avoidable hospital admissions. They will case-manage patients with frailty and long-term conditions, promoting independence and supporting individuals to live well in their own homes.
Main duties of the job
* Undertake clinical nursing practice using expert knowledge and clinical skills to deliver holistic care to patients living in their own home or care home.
* Collaborate closely with GPs and work independently to deliver safe, effective care to frail and housebound individuals, including those residing in care homes.
* Support all members of the Ageing Well team, providing guidance when necessary, conducting supervision and appraisals as required.
* Initiate and interpret tests and investigations within scope of practice.
* Administer and provide medications / treatments according to protocol and Patient Group Directions.
* Prescribe/supply medications (as appropriate) following policy, patient group directives and local pathways.
* Promote / support health & wellbeing, helping patients to remain independent and well at home.
* Facilitate patient education, self-management of disease, and behaviour modification to help reduce health inequalities.
* Conduct thorough person-centred needs assessment to develop care plans for each patient in a timely manner.
* Maintain and regularly update a comprehensive register of frail patients, utilising clinical frailty scoring tools to assess and monitor levels of frailty.
* Initiate the process of diagnosis with patients suspected to have a chronic disease e.g., diabetes, COPD, asthma, IHD referring to other clinical staff as appropriate.
* Proactively manage long term conditions alongside practice teams.
* Accurately update patient records on EMIS systems. All documentation must be timely, relevant, and clearly reflect the care provided.
* Directly admit patients to secondary care hospital in acute medical need.
* Promote clear communication with the health care team and support medication management.
* Communicate effectively with other healthcare professionals and make appropriate referrals to ensure coordinated, multidisciplinary care.
* Build and communicate therapeutic working relationships with a wide array of statutory and voluntary organisations for the benefit of patient care and facilitates good working relationships.
* Organise and chair multidisciplinary team (MDT) meetings, fostering effective working relationships with health, social care, and third-sector partners to ensure a seamless, integrated response for patients with complex needs or long-term conditions.
* Work flexibly across various healthcare settings, including surgeries, home visits, and community.
* Actively participate in clinical, PCN and practice meetings.
* Participate in team meetings, audits, and data collection for improving patient care.
* Support Social Prescribers / Care Coordinators in delivering high-quality care to frail and housebound patients.
* Provide expert clinical advice and support to patients, carers, and colleagues, maintaining high standards of professional practice and clinical excellence.
* Operate in line with clinical protocols and guidelines, ensuring professional, compassionate support for patients, families, and carers - using resources responsibly and efficiently.
* Contribute to service development through population health management tools by creating and implementing innovative models, methods, and practices to enhance primary care services for the frail population.
* Ensure compliance with practice CQC requirements and maintain accurate documentation.
* Work within all relevant PCN practice policies and procedural guidelines e.g., infection control, chaperoning, risk management.
* Contribute to PCN practice targets both local and national
* Develop own knowledge and practice to meet objectives/changes in service, through attendance on study days, self-directed learning, and reflection on practice.
* Participate in our appraisal system, matching organisational aims with individual objectives.
* Undertake all mandatory training required for the role.
* Maintain the highest standards of conduct and integrity
Person Specification
Essential
* Current UK NMC registration and maintains revalidation
* Relevant nursing or health degree
* Independent Prescriber
* History Taking and Physical Assessment
* Experienced and up to date in blood pressure, temperature, pulse, testing blood sugars, O2 sats, tissue/skin health, diabetic foot checks
* Up to date vaccinations and immunisations training for Covid/Influenza
* Evidence of continual professional development
* Full UK Driving Licence
Experience
Essential
* Two years recent primary or community nursing experience
* Knowledge of national standards that inform practice (NSF, NICE Guidelines)
* Experience of working in health, social care and other support roles in direct contact with people, families or carers (in a paid or voluntary capacity)
* Experience of working within multi - professional team environments
* Experience of supporting people, their families and carers in a related role
* Experience of working with elderly or vulnerable people, complying with best practice and relevant legislation
Knowledge and skills
Essential
* Understanding of Personalised Care
* Understanding of the wider determinants of health
* Knowledge of how the NHS works, including primary care and PCNs
* Ability to recognise/work within limits of competence, seeking advice if needed
* Understanding of the needs of older people / adults with disabilities / long term conditions particularly in relation to promoting their independence
* Basic knowledge of long-term conditions and associated complexities: medical, physical, emotional and social
* Clear, polite telephone manner
* Good interpersonal skills
* Ability to record accurate clinical notes
* Proficient in MS Office and web-based services
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