Job summary
The fundamental role
of the post holder is to meet the primary care needs of an identified group of
people identified as frail and needing further support in the community. The
post holder will liaise with SAHC clinicians and other community health and social
care providers to meet the identified needs of these patients.
Main duties of the job
This workload will involve reviewing medical issues and current problems,
completing medication reviews and dementia screening, developing a treatment
escalation plan, ensuring all appropriate assessments are completed and
developing and implementing an appropriate individualised plan of care. The
clinician will be expected to visit patients where required.
The service is designed to achieve the following:
- A fall in ambulance hospital journeys
required by residents of St Austell and Mevagissey who are deemed as frail
- A drop in hospital
attendances for these residents
- A reduction in hospital
admissions for these residents
- Improved Health and social care
support for these residents and their carers to help them to keep at home and
avoid hospital admission.
- Joined up pathways with acute
trust, ambulance service, community services, social services, community
voluntary services and end of life care to support admission avoidance.
Please note you will be required to drive across the St Austell and
Mevagissey area
About us
St
Austell Healthcare (SAH) formed in May 2015 comprising the four former
practices in St Austell. The GP surgery in Mevagissey joined in 2021. We have a
total list size of 37,400 patients. Were a Primary Care Network (PCN) in our
own right and winner of NAPC Primary Care Home award for 2019/20. The practice
offers unparalleled peer support, the chance to influence the future of
community based medical care and the opportunity to earn well alongside an
experienced and friendly team. We have a full range of ARRS roles including
CPNs, Physio, Paramedics, Pharmacists and Social prescribers amongst others.
Over
2024, six Integrated Neighbourhood Teams (INTs) were established within Central
Cornwall ICA, aligning with the six Primary Care Network (PCN) footprints.
These teams bring together multidisciplinary professionals across health,
social care, and community services to deliver integrated and equitable care.
Phases 1 and 2 of development focused on relationship-building and initial
collaboration, supported by the National Association of Primary Care (NAPC).
St
Austell PCN has been chosen as one of 2 INTs in our area to be a Wave 1
Integrated Neighbourbhood Team and expand this concept further into an
operational model delivering on key outcomes.
Job description
Job responsibilities
Clinical Responsibilities and Requirements
- To lead the Home Team Frailty program for the St Austell Integrated Neighbourhood Team.
- To assess, plan, implement and evaluate specialist treatment and care through personalised care plans to people on an allocated caseload; promoting independence and autonomy; working within a multi-disciplinary team.
- Supporting the Frailty GP in improving diagnosis and screening of people with dementia within the care home, this will be by the review of all care home residents.
- Act as an expert practitioner, demonstrating clinical competence and a sound knowledge base.
- Undertake consultations with patients including visiting in their own home or a care home environment.
- Assess patients with a range of acute, non-acute and chronic medical conditions.
- Advance own clinical knowledge, skill and competence based on current evidence through advanced educational programmes.
- Completing and sharing advanced care plans
- Partnership working with other providers to deliver seamless joined up care.
- Reviewing and making clinical decisions, including prioritisation of need.
- Provide highly specialist advice to others regarding the management and care of patients/service users.
- To demonstrate clinical effectiveness by use of evidence-based practice and outcome measures.
- Plan, implement and review health improvement programmes in a range of settings.
- Recognise, assess, and manage risk across the immediate and wider working environment and make appropriate decisions autonomously, ensuring statutory requirements are met.
- To be responsible for patient safety through knowledge of systems, legal requirements and understanding of litigation.
- To communicate effectively in verbal and written form in the exchange of highly complex, sensitive or contentious information in difficult situations using de-escalation, mediation, resolution and professional Duty of Candour.
- To evaluate care, taking appropriate action leading to improvement in quality standards through clinical audit, root cause analysis and dealing with complaints.
- Provision of support to carers considering what can put in place to support that persons mental health and wellbeing, by the use of tools to identify deterioration in wellbeing and mental state.
- Liaison between local organisations such as volunteering etc to provide services that can support the delivery of care within the patients own home.
- Setting up, referral to and attendance at MDTs involving a range of health and care professionals, from one or more organisations, working together to deliver comprehensive patient care. The benefits of such an approach can include improved health outcomes, enhanced satisfaction for the individual and a more efficient use of resources.
- Line manage team members
Professional
- Adhere to own professional body requirements and at all times work within the scope of professional practice.
- Ensure that professional practice adheres to organisational policies, procedures and guidelines.
- Maintain a professional manner and act as a role model and mentor for junior staff including trainees and student nurses.
- Maintain confidentiality with regard to information pertaining to patients and staff.
- Ensure that the service interfaces with all other departments in a professional and productive manner, providing an effective service to partner organisations and other service providers.
Job description
Job responsibilities
Clinical Responsibilities and Requirements
- To lead the Home Team Frailty program for the St Austell Integrated Neighbourhood Team.
- To assess, plan, implement and evaluate specialist treatment and care through personalised care plans to people on an allocated caseload; promoting independence and autonomy; working within a multi-disciplinary team.
- Supporting the Frailty GP in improving diagnosis and screening of people with dementia within the care home, this will be by the review of all care home residents.
- Act as an expert practitioner, demonstrating clinical competence and a sound knowledge base.
- Undertake consultations with patients including visiting in their own home or a care home environment.
- Assess patients with a range of acute, non-acute and chronic medical conditions.
- Advance own clinical knowledge, skill and competence based on current evidence through advanced educational programmes.
- Completing and sharing advanced care plans
- Partnership working with other providers to deliver seamless joined up care.
- Reviewing and making clinical decisions, including prioritisation of need.
- Provide highly specialist advice to others regarding the management and care of patients/service users.
- To demonstrate clinical effectiveness by use of evidence-based practice and outcome measures.
- Plan, implement and review health improvement programmes in a range of settings.
- Recognise, assess, and manage risk across the immediate and wider working environment and make appropriate decisions autonomously, ensuring statutory requirements are met.
- To be responsible for patient safety through knowledge of systems, legal requirements and understanding of litigation.
- To communicate effectively in verbal and written form in the exchange of highly complex, sensitive or contentious information in difficult situations using de-escalation, mediation, resolution and professional Duty of Candour.
- To evaluate care, taking appropriate action leading to improvement in quality standards through clinical audit, root cause analysis and dealing with complaints.
- Provision of support to carers considering what can put in place to support that persons mental health and wellbeing, by the use of tools to identify deterioration in wellbeing and mental state.
- Liaison between local organisations such as volunteering etc to provide services that can support the delivery of care within the patients own home.
- Setting up, referral to and attendance at MDTs involving a range of health and care professionals, from one or more organisations, working together to deliver comprehensive patient care. The benefits of such an approach can include improved health outcomes, enhanced satisfaction for the individual and a more efficient use of resources.
- Line manage team members
Professional
- Adhere to own professional body requirements and at all times work within the scope of professional practice.
- Ensure that professional practice adheres to organisational policies, procedures and guidelines.
- Maintain a professional manner and act as a role model and mentor for junior staff including trainees and student nurses.
- Maintain confidentiality with regard to information pertaining to patients and staff.
- Ensure that the service interfaces with all other departments in a professional and productive manner, providing an effective service to partner organisations and other service providers.
Person Specification
Qualifications
Essential
- Degree in Nursing or equivalent clinical qualification with NHC registration and 2+ years experience
- Eligible to work in the UK
- Meets DBS requirements
Desirable
- Prescribing qualification or commitment to one
Experience
Essential
- Frailty management in an acute setting.
- Frailty management in a community setting
- Creation/Review of care plans
- Experience of working to protocols or guidelines
Desirable
- Primary care experience
- Experience of lone working
- Knowledge of social services and voluntary sectors
- Experience in visiting patients in own home
Aptitude & Abilities
Essential
- Knowledge of UK NHS General Practice
- Good IT skills
- Excellent written and verbal communication skills
- Good organisational skills
Motivation
Essential
- Ability to work as part of a team
- Flexibility
- Self-motivated and self-managing
- Full UK driving licence and vehicle access
- Willingness to undergo additional training, education and mentoring to develop and maintain clinical skills
Person Specification
Qualifications
Essential
- Degree in Nursing or equivalent clinical qualification with NHC registration and 2+ years experience
- Eligible to work in the UK
- Meets DBS requirements
Desirable
- Prescribing qualification or commitment to one
Experience
Essential
- Frailty management in an acute setting.
- Frailty management in a community setting
- Creation/Review of care plans
- Experience of working to protocols or guidelines
Desirable
- Primary care experience
- Experience of lone working
- Knowledge of social services and voluntary sectors
- Experience in visiting patients in own home
Aptitude & Abilities
Essential
- Knowledge of UK NHS General Practice
- Good IT skills
- Excellent written and verbal communication skills
- Good organisational skills
Motivation
Essential
- Ability to work as part of a team
- Flexibility
- Self-motivated and self-managing
- Full UK driving licence and vehicle access
- Willingness to undergo additional training, education and mentoring to develop and maintain clinical skills
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.
UK Registration
Applicants must have current UK professional registration. For further information please see
NHS Careers website (opens in a new window).
Additional information
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.
UK Registration
Applicants must have current UK professional registration. For further information please see
NHS Careers website (opens in a new window).
