Welcome to Lowestoft Primary Care Home (PCH) team. One post available - up to full time hours.
We are seeking a Registered Nurse (Adult) with experience of supporting patients with long term chronic disease management to join our team. As core member of the PCH leadership team the Community Matron will ensure PCH patients with complex needs and those in crisis are treated effectively by providing independent specialist nursing input and clinical advice to patients and staff; lead on admission prevention, promote well-being and reduce demand on primary care and ECCH specialist services.
The successful candidate will have Non medical (v300) independent and supplementary prescribing qualification or confirm willingness to complete. This post is 80% clinically facing.
The PCH is a multidisciplinary team delivering health care to people in the coastal town of Lowestoft. The combined skills of the team mean they are able to respond to the changing needs of patients and support those who may previously been admitted to hospital to remain at home. You will become an active member within this team of clinicians.
The PCH team provides community services 7 days per week 07:00- 20:30 hours.
The core shift is 08:30- 16:30. Weekend and bank holiday working on a rotational basis as part of the Band 7 leadership role. The post is offered up to 37.5 hours per week. We are able to support flexible working arrangements and other shift patterns would be considered.
Main duties of the job
Develop and maintain clinical skills to meet the roles competency matrix that includes rapid top to toe assessment to identify and care for the deteriorating patient at home and the delivery of essential nursing care.
Lead on admission prevention by providing independent specialist nursing input and clinical advice to patients, staff, and carers.
Participate in rapid assessment for patients in their own home with a variety of acute, chronic, and age-related conditions.
Provide short-term case management for patients with complex health needs and who present in crisis or are deteriorating, to ensure they are treated effectively.
Provide clinical support and advice to other members of the PCH team on the care of the deteriorating patient.
Hold a short-term caseload of patients; using a variety of approaches such as health coaching and problem lists to identify the key actions, abilities, and motivations to support their health and well being.
Be the named nurse for identified General Practice(s), create relationships with the medical and non-medical care teams and practice management that ensure the timely referral and escalation of patients to the PCH and ECCH specialist services.
Provide clinical leadership, operational management, and professional support to other members of the multidisciplinary team within the PCH. This includes staff recruitment and retention, skill mix and team development.
Participate in the PCH Band 7 7-day leadership and virtual room rota.
About us
ECCH is well established health care provider and has been successfully delivering NHS care within the community since 2011. We provide a range of NHS, community health and social care services predominantly across the easterly region of the Norfolk/Suffolk borders.
We are aligned to NHS terms and conditions, and offer many employee benefits, to find out more about us visit our website - www.ecch.org. We are a social enterprise and staff owned organisation which means staff can opt to be shareholders and have a real say in how ECCH is run and evolves to deliver healthcare for the future.
At the heart of our ambition, we work in partnership with and for the community to become the provider and employer of choice for community healthcare.
We encourage you to apply as early as possible as this job may close earlier than the advertised closing date once enough applications have been received.
Lowestoft Primary Care Home is a multidisciplinary clinical team of health and social care professionals working in partnership partnership with Primary Care, Social Services, social care providers, other specialist community health teams and voluntary sector providers to ensure patients are able to remain in their own homes whenever possible.
Followingthe announcement of a 3.6% Agenda for Change pay award, this role will beeligible for a salary increase effective in August 2025 pay. Details of the newpay structure can be found on the NHS Employers website.
Job responsibilities
Contributeto, support and promote ECCHs, strategic direction, values and culture inrelation to proactive and reactive services.
Discuss alltreatment options with sensitivity, knowledge and expertise and to act as apatient advocate when appropriate and respecting patient confidentiality with privacyand respect for diverse cultural backgrounds and requirements.
Offer asupportive service to patients and their carers from diagnosis through allstages of the disease process, in conjunction with other healthcareprofessional using a range of communication skills to manage care andinformation empathetically.
Understandand support the achievement of ECCH business plan objectives and performancetargets, and initiate and participate in screening and needs assessment asrequired.
Superviseother health and social care professionals in the delivery of proactive healthpromotion activated, e.g. chronic disease management with individuals and groups.
Identifythe potential for service developments, risk and deficits and inform linemanager making recommendation based on specialist knowledge.
Provideleadership and management of locality nursing teams with identified lines ofresponsibility.
Plan andorganise a range of complex activities in a wide range of settings to ensurebest practice is delivered across your designated area of responsibility andthe wider community.
To provideclinical leadership within the Primary Care Home Team/s and the widerintegrated Community Care teams including Primary, Social Care, and all otherprovider organisations to provide high standards of care to patients and whereappropriate avoiding unnecessary admission to secondary care.
To be a keydriver for establishing integrated care teams both practically andbehaviourally.
Assist withthe implementation of pathways and guidelines to support health careprofessionals in establishing patient on evidence-based therapies.
Developsystems to monitor, evaluate and audit service quality in order to meetnationally and locally set targets and develop reporting mechanisms.
Effectivelycommunicate at all levels of the organisation, with a variety of healthprofessionals, users and carers, to provide the best health outcomes.
Maintain ahigh level of performance and be goal and outcome focussed when faced withopposition or when working under conditions or pressure.
Identifypotential service developments, risks and deficits and discuss with linemanager, making recommendations based on expert knowledge to enhance thecapacity and quality of community care.
Monitor andmaintain standards / provide benchmarking data to allow comparison with otherhealthcare providers
Participatein teaching and clinical supervision with nursing teams and other providerstaff as required
Criticallyevaluate research findings, national guidelines and implement changes inclinical practice as appropriate
Participatein clinical supervision with nursing teams as required.
Providepatients, families and carers with tailored education programmes, advice andsupport, that may precipitate symptoms of acute exacerbation of underlyingconditions or illness and include lifestyle changes that would be advantageousto health.
Beresponsible for participating and maintaining a learning environment andmaximise opportunities for education and development in the clinical area toenhance individual development and performance in the delivery of highstandards of care.
My Accountability,My Responsibility
Takeresponsibility for your own personal and professional development; maintaincompetence, knowledge and skills commensurate with role.
Using astandardised approach but with a high degree of professional autonomy andaccountability, work across Health, Social Care, Voluntary and other healthproviders and agencies, to identify a defined group of patients with complexneeds to provide a single plan of care co-produced with the patient.
Usingadvanced clinical practice skills assess the physical and psychosocial needs ofa defined client group.
Criticallyanalyse complex clinical data and information to inform diagnosis and, whereappropriate, order investigations and/or instigate therapeutic treatments toinform clinical decision making and improve health outcomes.
MaintainKey Worker responsibility for the patient when admitted to any inpatientfacility and provide baseline health data for the receiving team, to supportintegrated and consistent care and facilitate Community Led discharge. Behighly visible and accessible to patients, families and carers and be seen asbeing in charge of their care.
Provideindividualised care plan for patients with Long Term Conditions, so that theircondition remains as stable as possible and, where appropriate, hospitaladmission is prevented and early discharge facilitated.
Analysecomplex patient situations establishing a therapeutic relationship in whichthey are able to utilize counselling skills to assist the individual to adjustto their illness and care.
Useassessment tools/skills that will ensure an appropriate level of nursing ortherapeutic intervention so that patients who present with highly complex needsare timely referred to the appropriate specialist.
Be whollyaccountable for practice taking every reasonable opportunity to sustain andimprove knowledge and professional competence and, ensure that all aspects ofprofessional behaviour as required within Nursing and Midwifery Council Codeare followed at all times.
Maintainlegible, accurate and contemporaneous patient records in accordance with ECCHPolicy and the Nursing and Midwifery Council standards for record keeping.
Assist withthe investigations of complaints, participate in the risk management process,critical incident reporting, evaluation, dissemination and change in practice.
Beresponsible for understanding, following and implementing ECCH policies andprocedures, and influencing working practices to support this accordingly.
Contributeto the clinical governance agenda through participation in clinical riskassessment and management, clinical audit.
Create anenvironment conducive to effective working, respecting and supporting staff todeliver high quality clinical services.
Ensure ahigh standard of record keeping is achieved in line with ECCH and professionalstandards.
Takeresponsibility to ensure compliancy with Health and Safety Policy, Fire andEnvironmental Waste Regulations.
RespectOur Resources: People, Time and Money
Takeresponsibility for the cost effective management and use expensive and highlycomplex equipment, provide recommendations for effective use of resources andcontribute to the effective delivery of cost improvement planning.
Analyse,interpret compare and contrast complex information, service requirements andoptions ensuring the effective approaches to service delivery and team working.
Contributeto the ongoing review of the wound care formulary and guidelines.
Evaluatethe impact of training programmes, for patient and carers, to ensure that theyprovide the necessary knowledge and skills to gain independence, safely managechanging circumstances and plan for unavoidable progression of conditions.
Work Together, Achieve Together
Usingadvanced generalist clinical skills to evaluate the delivery of care,identifying subtle changing health care needs. Being able to completely discusstreatment options with other generalists and specialists.
To be anintegral member of the primary care network team, working with a shared visionand developing caseloads in partnership with each other to deliver bothproactive and reactive care.
Demonstrateresponsibility and accountability for the clinical caseload and co-ordinatecare across the whole patient pathway within ECCH. This included ensuring arobust relationship and constant interface with OOHT and secondary care asrequired.
Workingwith partners in Primary and Social care to develop a model of care whichidentifies and case manages those patients needing complex chronic diseasemanagement or palliative care supporting the needs of the local community.
Negotiateand agree with the patient carers and other healthcare professionals,individual roles and responsibilities with actions to be taken and outcomes tobe achieved, referring on to other services or professionals as appropriate.
Work inpartnership with the patients to empower them to make informed choices abouttheir healthcare and support choices about end of life care.
Establishlocal networks in partnership with other health and socialprofessionals/agencies and national links with other generalists in order todevelop protocols according to national and local guidelines for the safe andeffective provision of a community nursing services.
Work withpartners in nursing and residential care to provide proactive care to improvethe health outcomes of the residents and so prevent unnecessary hospitaladmissions or extended in- patient care episodes.
Provideprofessional expertise and clinical leadership, acting as a resource to otherprofessionals within and outside your own organisation, regarding clinicalissues to ensure continuous service provision and inter-professional working.
Work withECCH Colleagues, and other partner agencies and stakeholders including theacute trust to contribute to the development and delivery of new innovativemodels of service delivery, ensuring a leading edge approach to servicedevelopment in-line with evidence
basedpractice.
All roles within East Coast Community Healthcare CIC(ECCH) require staff to demonstrate our Values and Signature Behaviours in thecare and service they provide to patients, service users, stakeholders andcolleagues. All members of staff should consider these as an essential part oftheir job role.
Please see attached job description for full duties.
Person Specification
Personal Attributes
* Ability to embrace our Culture, Values and Signature Behaviours:
* (Compassion - We Listen, We Learn, We Lead| Action - My Accountability, My Responsibility | Respect - Respect Our Resources: People, Time and Money | Everyone - Work Together, Achieve Together).
* Commitment to lifelong learning
* Flexible team orientated approach to work
* Willingness and ability to work across different sites
* The ability to travel across the community
* Passion and enthusiasm to deliver person centred care
* Self-motivated and solution focused
Qualifications
* Professional registration with Nursing and Midwifery Council (NMC) Registered Nurse Level 1 (Adult)
* BSc Nursing Practice or equivalent
* Evidence of post registration study at Postgraduate Level
* Independent Nurse Prescribing or willing to undertake
* Leadership and management qualification
* Advanced communication skills
* Health Coaching Programme
Skills and Knowledge
* Competent IT skills ability to use electronic diary and electronic clinical record systems and MS Office software
* Proven ability to problem-solve
* Extensive clinical skills
* Evidenced experience of negotiating and influencing skills
* Excellent interpersonal skills, including communication with different stakeholders
* Advanced communication skills
Experience
* Extensive clinical experience from a range of settings including secondary and community care
* Experience of case management
* Experience of long term/ chronic disease management
* Evidence of experience of partnership working with other care agencies eg Social services/ voluntary sector/ primary care
* Experience of team leadership.
* Experience of working within primary care
* Experience of complaint investigation
* Experience of facilitating clinical supervision
* Experience of audit
Disclosure and Barring Service Check
This post is subject to the Rehabilitation of Offenders Act (Exceptions Order) 1975 and as such it will be necessary for a submission for Disclosure to be made to the Disclosure and Barring Service (formerly known as CRB) to check for any previous criminal convictions.
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