Community Frailty Nurse Housebound & Care Home

Job responsibilities

Community Frailty Nurse Housebound & Care Home

ARRS Experience General Practice Nurse

Main Duties

Applicants should be experienced general practice nurse who, acting within their professional boundaries, will provide care for housebound and care home patients including initial history taking, clinical assessment, diagnosis, treatment, and evaluation of care.

Lead long-term condition management focusing on elderly, frail, and housebound patients, including those in care homes.

They will demonstrate safe clinical decision-making and expert care, including assessment and diagnostic skills, for housebound and care home patients within the general practice setting.

The post holder will demonstrate critical thinking in the clinical decision-making process, with the ability to prioritise and triage the needs of the patients, accordingly, instigating appropriate investigations or referrals to colleagues and other care providers.

They will work collaboratively as part of the general practice multidisciplinary team to meet the needs of patients. The role is both varied and diverse with clinical support and mentorship provided to allow the successful candidate to flourish. The workload will consist of a mixture of home visits, care home visits and telephone consultations.

Job description and Person Specification

Job responsibilities,

To work as part of a multi-disciplinary team across the PCN to care for our housebound and care home patients, including proactive assessment, diagnosis and treatment of individuals using a holistic approach.To undertake care home weekly ward rounds.

To assess, diagnose, investigate, treat, refer or signpost patients/service users within the community with undifferentiated or undiagnosed condition relating to minor illness, minor injury or urgent problems.

The post holder will use advanced clinical skills to provide education to service users, promoting self-care and empowering them to make informed choices about their treatment.

The post holder must have access to a vehicle for home visits with mileage expenses remunerated by submission of a monthly mileage form. (Please note it is the postholders responsibility to ensure that their car insurance is covered for business use).

Visiting patients who are frail/have co-morbidities in their homes or in a care home. Supporting with care home ward rounds with the support of the PCNs Community Frailty Practitioner and Care - Coordinator

May be required to help with the Avoiding Unplanned Admission reviews

Consult with patients, take medical histories, perform physical examinations, analyse, diagnose and explain medical problems during consultations and home visits.

Recommend and explain appropriate diagnostic tests and treatment.

Formulate differential diagnoses and develop and deliver appropriate treatment and management plans. Request and interpret results of laboratory investigations when necessary.

Advanced end of life care planning to include ReSPECT discussions and development of Personalised Care and Support Plans.

Advise patients on general health care and minor ailments, with referral to other members of the primary and secondary health care team as necessary.

Undertake assessment for patients within their place of residence using diagnostic skills, initiation of investigations and feeding back to the patients GP where appropriate.

To help manage/support patients with their long term condition.

Leads long-term condition management across the PCN.

Support quality improvement and assurance initiatives within the PCN.

Promote public health and screening programs, including immunisations and cervical screening.

Integrate population health management approaches to reduce health inequalities.

Support, mentors, and supervises new-to-practice nurses and other healthcare professionals within the PCN. To impart knowledge and skills to colleagues, both formally and informally by promoting peer review and best practice within the work environment.

Work collaboratively with the wider practice team to enhance patient care.

Work with local and national evidenced based policies and procedures.

To communicate at all levels within the team ensuring an effective service is delivered.

Ensure evidenced-based care is delivered at the highest standards ensuring delivery of high-quality patient care.

Administration and professional responsibilities

Works as an autonomous practitioner, in accordance with regulatory requirements as defined by the Health & Care Professions Council standards. Ensure that personal and professional clinical standards are maintained.

Ensure clinical practice is safe and effective and remains within boundaries of competence, and to acknowledge limitations

Enhance own performance through Continuous Professional Development, imparting own knowledge and behaviours to meet the needs of the service.

To participate in the audit process, QOF (Quality and Outcomes Framework) evaluation and implementing plans and practice or PCN change to meet patient need including participating in the administrative and professional responsibilities of the practice team.

Ensure the patients records within the Practice clinical computer system is kept up to date, with accurate, contemporaneous details recorded

Ensure appropriate items of service claims are made accurately, reporting any problems to the PCN Manager.

Communicate, when necessary with colleagues in the PCN in order to discuss or refer specific patients, plan and co-ordinate activities or exchange information in order to improve the quality of patient care.

Send and receive written information on behalf of the Practices within the PCN regarding matters relating to the physical and social welfare of patients.

Attend regular multi-disciplinary meetings organised by the Practices within the PCN to discuss the health and social needs of particular patients.

Undertake care home weekly ward rounds.

Be aware of data protection (GDPR) and confidentiality issues particularly within a PCN

Use technology and appropriate software as an aid to management in planning, implementation, and monitoring of care, presenting and communicating information.

Review and process data using accurate SNOMED codes to ensure easy and accurate information retrieval for monitoring and audit processes.

Qualifications

Essential

• Batchelor Degree in Life Science/Biomedical/Nursing or Allied Health Science or equivalent
• Health & Care Professions Council (HCPC) registration.
• Holds more than one academic Level 6 diploma
• postgraduate certification in long-term conditions care
• and/or public health initiatives.
• is working at Registered Nurse Level Practice as described in the Primary Care and General Practice Nursing Career and Core Capabilities Framework
• Full UK driving license and access to vehicle (for home visits as required)

Desirable

• Minimum 3 years post-registration experience.
• Non-medical prescribing qualification

Other

Essential

• Meets DBS reference standards and criminal record checks
• Willingness to work flexible hours when required to meet work demands
• Access to own transport and ability to travel across the locality to visit people in their own homes.
• Awareness of data protection (GDPR) and confidentiality issues particularly within a healthcare setting.

Personal attributes & abilities

Essential

• Ability to co-ordinate and prioritise workloads able to multi-task as well as be self-disciplined and highly motivated.
• High degree of personal credibility, emotional intelligence, patience, and flexibility
• Ability to cope with unpredictable situations.

Desirable

• Confident in facilitating and challenging others
• Demonstrates a flexible approach to ensure patient care is delivered.

Specialist knowledge/skills

Essential

• IT literate / proficient in the use of the computer
• Excellent interpersonal and organisational skills
• Good problem solving and decision-making skills
• Ability to manage workload effectively
• A high standard of clinical skills and experience of using these skills in different situations.
• Willingness to always work towards the best interest of the patient.
• Team player / ability to liaise effectively with colleagues and other members of the multi-disciplinary team.
• Ability to write comprehensive, accurate clinical notes, implement and evaluate care plans.

Desirable

• Understand own scope of practice, the context of continual learning and the need to develop constantly to ensure safe, competent and confident practice.
• Evidence of success in efficient and effective project and program management

Experience

Essential

• Experience of working to protocols or guidelines.
• Experience in frailty care, chronic disease management, and care planning in community or primary care settings
• CDM Management
• Ongoing evidence of CPD

Desirable

• Experience of offering mentorship and supervision to other nursing staff.
• Experience of developing and implementing training programs.
• Experience of working in care homes

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).