Job summary
The post holder is registered with the NMC and will be able to provide support for acute, chronic and proactive care across varying settings to our frail patients, whilst working within their professional boundaries.
Our service is supported by and consists of a diverse multi-professional workforce which includes pharmacists, care coordinators, social prescribing link workers, nurses, paramedics, ACPs, a digital transformational lead and an occupational therapist. The role will be supported by direct clinical supervision to support comprehensive assessment, care planning and intervention delivery for older adults with frailty.
The post holder will use systems to accurately record patient care/contacts using relevant clinical and other reporting templates to ensure outcomes are coded correctly in the clinical systems and other tools as required in line with local and national targets.
There will be some lone working with patients and the role will be based across a number of settings.
Main duties of the job
To provide nursing activities which include the followingresponsibilities;
Assist in the management of care treatmentplans for patients at risk of developing a long-term condition and patientswith acute and chronic conditions.
Demonstrate a high level of interpersonal, communicationand IT skills to communicate effectively with patients and internal andexternal colleagues.
Within your scope of practice independentlyundertake and develop care plans and treatments, care coordination, onwardsreferral to appropriate community and specialist services, as appropriate,ensuring a seamless care approach.
Work within a wider multi-disciplinary team toensure effective care plans and treatments are in place for complex patientpalliative care and long term conditions. This will include participating inPCN Multi-Disciplinary Team meetings, as required.
Help prepare patients and their carers/familiesfor changes in condition which can include support for choice about end of lifecare.
Liaise with appropriate clinical service staffand managers to undertake any required clinical audits and interpretation offindings as required.
Participate in management and review ofpatient complaints and significant events and identify learning from these.
Support patients to adopt health promotionstrategies that promote healthy lifestyles and apply principles of self-care.
About us
Our Primary Care Network
Preston Park PCN is a group of five surgeries - Beaconsfield Medical Practice, The Haven Practice, Preston Park Surgery, Stanford Medical Centre and Warmdene Surgery. We serve approximately 57,000 patients and aim to support and connect with our local community.
Primary Care Networks (PCNs) bringGP practices together with other local services such as community, mental health, social care and the voluntary sector to look after local populations. PCNs will help to joinupservices at a local level, focusing on the specific needs of these local populations, with patients still accessing routine GP appointments as they do now.
Job description
Job responsibilities
Job Summary
The post holder is registered with the NMC and will be able to provide support for acute, chronic and proactive care across varying settings to our frail patients, whilst working within their professional boundaries.
Our service is supported by and consists of a diverse multi-professional workforce which includes pharmacists, care coordinators, social prescribing link workers, nurses, paramedics, ACPs, a digital transformational lead and an occupational therapist. The role will be supported by direct clinical supervision to support comprehensive assessment, care planning and intervention delivery for older adults with frailty.
The post holder will use systems to accurately record patient care/contacts using relevant clinical and other reporting templates to ensure outcomes are coded correctly in the clinical systems and other tools as required in line with local and national targets.
There will be some lone working with patients and the role will be based across a number of settings.
Key Responsibilities
To provide nursing activities which include the following responsibilities;
1. Assist in the management of care treatment plans for patients at risk of developing a long-term condition and patients with acute and chronic conditions.
2. Assist with the management of patients with active and long term conditions.
3. Demonstrate a high level of interpersonal, communication and IT skills to communicate effectively with patients and internal and external colleagues.
4. Within your scope of practice independently undertake and develop care plans and treatments, care coordination, onwards referral to appropriate community and specialist services, as appropriate, ensuring a seamless care approach.
5. Work with patients, carers and families as needed, in order to support compliance with and adherence of prescribed treatments.
6. Work within a wider multi-disciplinary team to ensure effective care plans and treatments are in place for complex patient palliative care and long term conditions. This will include participating in PCN Multi-Disciplinary Team meetings, as required.
7. Demonstrate a thorough understanding of and commitment to equality of opportunity for patients and colleagues and awareness and commitment to diversity.
8. Help prepare patients and their carers/families for changes in condition which can include support for choice about end of life care.
9. Liaise with appropriate clinical service staff and managers to undertake any required clinical audits and interpretation of findings as required.
10. Maintain good working relationships internally and externally.
11. Participate in management and review of patient complaints and significant events and identify learning from these.
12. Support patients to adopt health promotion strategies that promote healthy lifestyles and apply principles of self-care.
Care Home and Frailty Team:
- Offering support for Residential and housebound patients as needed:
13. Provide acute and at times same day care to residential home residents, in keeping within competence, assisting in a weekly care home ward round and review of patients ongoing acute/chronic needs, treatment and evaluation of care.
14. Support the management and review of chronic conditions, including contributing to PCN and practice targets required in line with local and national targets.
15. To assess the physical and psycho-social needs of housebound and residential, utilising the appropriate tools to complete care plans and ReSPECT forms.
16. Appropriately handover any acute clinical conditions that present during the patient review to the relevant clinical lead and make any relevant onward referrals.
17. Support care home staff with education and health promotion to help develop their knowledge and skills required to deliver excellent and safe care to patients.
18. Support the management and maintenance of the patient list.
19. Support the coordination of any project plans, resources, and communications.
20. Provide vaccinations (consent and administration) to patients and sometimes internal and external staff appropriately and ensure accurate record keeping.
21. Store and transport vaccines appropriately ensuring cold chain maintained.
22. Support the management and maintenance of the patient list.
23. Support the coordination of any project plans, resources, and communications.
24. Provide Annual Health Reviews and vaccinations (consent and administration) to patients appropriately and ensure accurate record keeping.
25. Store and transport any vaccines appropriately ensuring cold chain maintained.
26. Support the management and maintenance of the patient list.
27. Support the coordination of any project plans, resources, and communications.
Leadership Role:
28. Assist in the leading on the coordination of project plans, resources, communications, and patient lists for PCN services and ad hoc projects if required.
29. Assist in in the leading on the production and implementation of clinical and non-clinical guidelines and protocols if required.
30. Work within the parameters of agreed budgets and scope of service and/or project delivery.
31. Support service review and development including producing service performance reports and option papers for service developing and improvement.
32. Undertake mentorship and clinical supervision, if appropriate, for more junior staff, assessing competence against set standards of care.
Other:
33. Demonstrates a passion for improving the quality of care for patients.
34. Takes responsibility for own learning and performance including participating in clinical supervision and acting as a positive role mode.
35. Demonstrates respectful and professional communication and other behaviours to internal and external colleagues.
36. Values the contributions of other PCN staff and practice staff.
37. Maintaining professional relationships
The above is not an exhaustive list of duties and you will be expected to undertake such tasks that may reasonably be expected within the scope, level of skill and knowledge for this band.
Communication
38. Act as an advocate for patients and colleagues.
39. Communicate effectively with patients and carers, recognising the need for alternative methods of communication to overcome different levels of understanding, cultural background and preferred ways of communicating. To ensure patients are fully informed and consent to treatment and the sharing of information with other care providers. This is to be documented and recorded in the electronic patient record.
40. Communicate with and support patients who are receiving difficult news.
41. Maintain effective communication across PCN Teams, practice staff and with external stakeholders.
Person Specification
Experience
Essential
1. Ability to maintain effective working relationships and to promote collaborative practice with internal and external colleagues
2. Clean driving licence and access to a car with appropriate business insurance
3. Current registration with Nursing and Midwifery Council and up to date with mandatory training and revalidation
4. Experience of working with long term conditions
5. Good level of communication skills both verbal and written which can be tailored to a wide range of stakeholders
6. Good level of ICT knowledge and skills
7. Good organisational skills and time management
8. Professional, calm and efficient manner
9. Self-motivated, can work well independently and within a team
10. Works safely and effectively when working autonomously and in conjunction with other health care professionals
11. No afraid to ask for help when needed, recognising ones own sphere of competence and safety
Desirable
12. Evidence of post qualifying and continuing professional development
13. Experience of working with complex patients patients in a residential home setting and patients with learning disabilities
14. Experience of working within General Practice
15. Advanced Physical Assessment (Or willing to work towards)