Job summary
The post
holder will be responsible for the complex care provision of support to Taunton
Central Primary Care Network which will include attending and developing the multidisciplinary
team (MDT) for Care Homes, who are
responsible for managing the care of people registered with practices within Taunton
Central PCN.
The Post holder will require to work in different practices within the area so will require a degree of flexibility and a range of duties that may vary
as the service develops.
The post holder will contribute to
tackling inequalities in health and social care particularly regarding individuals
with long-term conditions in care homes. An ethos of promotion of independence
and partnership-working is integral to this post.
The post holder will contribute towards
quality improvement implementation with education and initiatives, supporting
care homes to deliver good quality of care in line with NHS NICE guidance for
care homes, the NHS Long Term Plan, and the Enhanced Health in Care Homes
(EHCH).
The post holder will assist in monitoring practices weekly care home rounds
and check ins
They will attend the weekly Care Home
MDTs.
The post holder will be required to
lead and deliver on the provide personal care planning for residents including
the completion of Treatment Escalation Plans in care homes, whilst working alongside
other members of the EHCH Team and multi-disciplinary team.
Main duties of the job
Meetings: Attend MDT for Care Homes and regular
meetings with Clinical Leads and Care Coordinators.
Identification: Support General Practices
Clinicians, Care Home Staff, Care Coordinator for Care Homes and and Occuapational
Therapist for Care Homes in Identification
for Personal Care Planning and Care Home MDTs.
Provide background
information about individuals for the weekly MDT meetings.
Management of Registers: Review service
users as required following MDTs using CGA approach; Support updates and
development of TEPs and Personalised Care and Support Plans (PCSP); check
policies on oral health, nutrition, wound care, falls, continence, and
dentition; work with Pharmacists on Structure Medication Reviews (SMRs).
Referral: good awareness of referral
pathways when necessary.
Admission avoidance and Transfer of Care: Support discharge of patients with Discharge to Assess team.
Liaise with Somerset Coordination Hub to avoid admissions.
Training: support Practices with TEPs
(meaningful), CGA, MDT engagement, care pathways e.g., nutrition, falls, catheter.
QI: Engage with QI approach as
required for measures and outcomes.
Coding: ensure use of correct codes i.e., SNOMED
for QOF.
Develop excellent working
relationships with all partners, wider service networks including the voluntary
sector, adult social care, hospitals, community pharmacists and other members
of the MDT.
About us
Taunton Central Primary Care Network is a relatively new organisation but our five member practices have a strong history of collaborative working to develop the best patient-centred care and services. The PCN has approximately 60,000 patients registered with four practices in Taunton and one practice in the neighbouring village of Bishops Lydeard. We pride ourselves on our ability and willingness to adopt innovative ways of working that improve patient care and make our PCN a rewarding place to work.
Job description
Job responsibilities
Organise and prioritise workload and work flexibly in response to
competing demands.
Support the Care Coordinators with the reporting required and associated
within the NHSE DES specifications for required services.
IT requirements for recording activity are adhered to in collaboration
with other team members.
Accurately update clinical GP systems as required.
Provide agreed performance/activity data within the MDT and PCN and to
wider organisations as requested.
Manage a caseload of patients identified
through the MDT.
Supporting training in Care Homes and
mapping gaps in staff knowledge as an outcome from MDTs
Holistically bring together all
a persons identified care and support needs and explore options to meet these
within a single personalised care and support plan (PCSP), in line with PCSP
best practice, based on what matters to the person.
Work with practice team/care
coordinator/clinical leads on supporting transfers of care (including hospital
admissions and discharges) plus out-of-hours calls and present this information
to the MDT as required.
Use risk stratification
tools to provide information on frequent flyers and service users with high
need, working with the Care Coordinator and Clinical Lead
Support the Care Coordinator
with new referrals by checking criteria, and where criteria have been met,
direct referral to the MDT.
Effectively recognise and manage challenging behaviours in carers and or relatives.
Provide information to
patients, their carers and/or relatives on behalf of the team.
Follow through actions identified
by the MDT including carrying out CGA (Complete Geriatric Assessment) arranging
tests, referrals, signposting, etc.
Working with the Pharmacists
to support person centered Structured Medication Reviews, work with service users
and carers to help
communicate changes/adherence.
Implement and lead Quality
Improvement projects.
Caring out care home rounds
and coordinating care with the Lead GP.
Support colleagues with care
home rounds where required.
Job description
Job responsibilities
Organise and prioritise workload and work flexibly in response to
competing demands.
Support the Care Coordinators with the reporting required and associated
within the NHSE DES specifications for required services.
IT requirements for recording activity are adhered to in collaboration
with other team members.
Accurately update clinical GP systems as required.
Provide agreed performance/activity data within the MDT and PCN and to
wider organisations as requested.
Manage a caseload of patients identified
through the MDT.
Supporting training in Care Homes and
mapping gaps in staff knowledge as an outcome from MDTs
Holistically bring together all
a persons identified care and support needs and explore options to meet these
within a single personalised care and support plan (PCSP), in line with PCSP
best practice, based on what matters to the person.
Work with practice team/care
coordinator/clinical leads on supporting transfers of care (including hospital
admissions and discharges) plus out-of-hours calls and present this information
to the MDT as required.
Use risk stratification
tools to provide information on frequent flyers and service users with high
need, working with the Care Coordinator and Clinical Lead
Support the Care Coordinator
with new referrals by checking criteria, and where criteria have been met,
direct referral to the MDT.
Effectively recognise and manage challenging behaviours in carers and or relatives.
Provide information to
patients, their carers and/or relatives on behalf of the team.
Follow through actions identified
by the MDT including carrying out CGA (Complete Geriatric Assessment) arranging
tests, referrals, signposting, etc.
Working with the Pharmacists
to support person centered Structured Medication Reviews, work with service users
and carers to help
communicate changes/adherence.
Implement and lead Quality
Improvement projects.
Caring out care home rounds
and coordinating care with the Lead GP.
Support colleagues with care
home rounds where required.
Person Specification
Qualifications
Essential
- Registered Nurse with Nursing and Midwifery Council
- Masters degree required for qualification post December 2020 refer to RCN Credentialing for Advanced Level of Nursing Practice.
- Qualified Independent Nurse Prescriber on the NMC register
- Meets NMC revalidation requirements in accordance with the NMC Revalidation booklet
- Meets the standards for registered ANP working at advanced level.
-
- Minor illness qualification
Desirable
- Qualified triage nurse
- Teaching qualification
- ALS and PALS
Experience
Essential
- Experience of practice within the four pillars
- Job plan that demonstrates advanced nursing practice and has equity with peers working at this level.
- Experience of prescribing and undertaking medication reviews
- Experience of working in a primary care environment
- Wound care/removal of sutures and staples
- Clinical knowledge and skills including:
- ECGs
- Venepuncture
- New patient medicals
- Chaperone procedure
- Requesting and processing pathology tests
- Advising patients accordingly
- Diabetes
- Hypertension
- Asthma
- Spirometry
- CHD
- Immunisations (routine and childhood)
- Understand the importance of evidence-based practice.
- Broad knowledge of clinical governance
- Ability to record accurate clinical notes.
- Ability to work within own scope of practice and understand when to refer to GPs.
- Knowledge of health promotion strategies
- Understand the requirement for PGDs and associated policy.
- Polite and confident, flexible and cooperative
- Motivated, forward thinker
- Problem solver with the ability to process information accurately and effectively, interpreting data as required.
- High levels of integrity and loyalty
- Sensitive and empathetic in distressing situations as well as ability to work under pressure/in stressful situations.
Desirable
- Knowledge of public health issues in the local area
- Awareness of issues within the wider health arena
- Experience of working as a practice nurse or community nurse
Other requirements
Essential
- Disclosure Barring Service (DBS) check
- Occupational health clearance
- Meet the requirements and produce evidence for nurse revalidation
- Evidence of continuing professional development (CPD) commensurate with the role of an ANP
- Access to own transport and ability to travel across locality on a regular basis
- Flexibility to work outside core office hours if required on occasion
Person Specification
Qualifications
Essential
- Registered Nurse with Nursing and Midwifery Council
- Masters degree required for qualification post December 2020 refer to RCN Credentialing for Advanced Level of Nursing Practice.
- Qualified Independent Nurse Prescriber on the NMC register
- Meets NMC revalidation requirements in accordance with the NMC Revalidation booklet
- Meets the standards for registered ANP working at advanced level.
-
- Minor illness qualification
Desirable
- Qualified triage nurse
- Teaching qualification
- ALS and PALS
Experience
Essential
- Experience of practice within the four pillars
- Job plan that demonstrates advanced nursing practice and has equity with peers working at this level.
- Experience of prescribing and undertaking medication reviews
- Experience of working in a primary care environment
- Wound care/removal of sutures and staples
- Clinical knowledge and skills including:
- ECGs
- Venepuncture
- New patient medicals
- Chaperone procedure
- Requesting and processing pathology tests
- Advising patients accordingly
- Diabetes
- Hypertension
- Asthma
- Spirometry
- CHD
- Immunisations (routine and childhood)
- Understand the importance of evidence-based practice.
- Broad knowledge of clinical governance
- Ability to record accurate clinical notes.
- Ability to work within own scope of practice and understand when to refer to GPs.
- Knowledge of health promotion strategies
- Understand the requirement for PGDs and associated policy.
- Polite and confident, flexible and cooperative
- Motivated, forward thinker
- Problem solver with the ability to process information accurately and effectively, interpreting data as required.
- High levels of integrity and loyalty
- Sensitive and empathetic in distressing situations as well as ability to work under pressure/in stressful situations.
Desirable
- Knowledge of public health issues in the local area
- Awareness of issues within the wider health arena
- Experience of working as a practice nurse or community nurse
Other requirements
Essential
- Disclosure Barring Service (DBS) check
- Occupational health clearance
- Meet the requirements and produce evidence for nurse revalidation
- Evidence of continuing professional development (CPD) commensurate with the role of an ANP
- Access to own transport and ability to travel across locality on a regular basis
- Flexibility to work outside core office hours if required on occasion
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).
