Job summary
Are you an experienced complex care nurse with a passion for providing patients with proactive and personalised health care? Would a holistic approach, working in partnership with a patient and other professionals, to identify and meet their health, social and self-care needs, bring you job satisfaction? Are you someone who thrives when contributing to the development of patient services and building teams? Do you have good leadership skills? If so, please read on as this could be the opportunity for you.
An exciting opportunity to join our network of five GP surgeries and help build a new cross-surgery team which will be dedicated to providing proactive and personalised care to patients through multi-disciplinary working.
Clinical and operational support from:
An Occupational Therapist
Community and Health Inequality & Access Care Coordinators
Project Manager
Administration Assistants (to be appointed)
Established and effective multidisciplinary working relationships across our surgeries, with the local health coaching and village agent teams as well as significant developing relationships with other local healthcare, social care and voluntary sector organisations
Annual one-to-one appraisal; training to support your personal development.
Eligibility for an NHS Pension
Main duties of the job
We are looking for a dedicated, multi-skilled nurse to develop our PCNs
proactive care offering to patients, as well as help build the team which will
deliver that service. The appropriate candidate will have excellent clinical,
problem solving and leadership skills and be confident to liaise with
practitioners/individuals at all levels and of all disciplines across our local
healthcare, social care and voluntary sector communities. You should be
confident to make autonomous decisions and thrive when presented with complex
care needs. You should also enjoy supporting team members to develop to the best
of their capabilities.
This role is intended to become an integral part of the PCNs
multidisciplinary team, working alongside health and wellbeing coaches and
social prescribing link workers to provide an all-encompassing approach to
personalised care and promoting and embedding the personalised care approach
across the PCN. It will also be an important clinical leadership role as the
PCN and its workforce and workstreams develop. Supported by the relevant PCN GP
Clinical Leads, the postholder will be required to provide day-to-day clinical
supervision of and clinical leadership for the PCNs Community Team and
Proactive Care workflow staff.
The post-holder will be required to work across the five surgeries of
the Network. They will also work in the community and in patients homes.
Therefore, the post-holder will require flexibility and be able to travel
between locations.
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..
Interviews are expected to take place week commencing the 27 January 2025.
Job description
Job responsibilities
The Community Complex Care Nurse will play a key role
within Taunton Central PCN, identifying and working with patients who would
benefit from proactive care, including but not limited to:
-
patients
living with moderate or severe frailty, or likely to become frail in next 10
years;
-
patients
experiencing health inequalities; and / or
-
patients
relying on unplanned care to manage their conditions
Where integrated community-based services could better
support those patients to manage their:
-
physical
and mental health needs;
-
social
care needs; and
-
self-care.
Supported by a multi-disciplinary team, the Community
Complex Care Nurse will have day-to-day responsibility for ensuring PCN
patients - who have been identified as appropriate for receiving the proactive model
of care, and allocated to them - receive:
-
An
holistic assessment to identify the patients health, social and self-care
needs and goals;
Personalised
care and support planning, to include but not limited to:
- collation of personalised, baseline and goals information.
- preparation of a Personalised Care and Support Plan
(PCSP); that plan to be regularly reviewed, updated and implemented to meet the
patients changing needs and goals; and
- subject to relevant training, preparation of a Treatment
Escalation Plan (TEP), if appropriate for the patient;
Multidisciplinary
working to address and meet the patients needs and goals, to include support
to navigate the care and support available to them across local health and care
services;
Co-ordinated
care, to include but not limited to:
- the promotion of self-care; and
- supporting patients to access the services and support
they require to understand and manage their own health and wellbeing (e.g.
making referrals village agents/social prescribing link workers, health and
wellbeing coaches, and other professionals as and when appropriate);
-
Intervention
and support at a level appropriate to their need and as identified as part of
their holistic assessment, personalised care and support planning and
multidisciplinary working.
The post-holder will work closely with patients usual
GPs, surgeries and the PCNs health care teams, to manage a caseload of
patients. They will act as the single point of contact for those teams, and
external health and social care providers, to ensure the appropriate support is
made available to their caseload of patients and their carers; supporting the
patients to understand and manage their condition and ensuring their changing
needs are addressed.
This is achieved by bringing together all the
information about a persons care and support needs and exploring options to
meet these within a single personalised care and support plan, based on what
matters to the person and through multidisciplinary and coordinated working, to
include self-management of needs by the patient at home.
The post-holder will be a dedicated, reliable and patient-focused
healthcare professional. They will enjoy working with a wide range of people, delivering
personalised care and the challenge, and rewards, of setting up and developing new
services. They will have excellent written and verbal communication skills, adopt
a holistic and personalised approach to care delivery, and have good organisational
and time management skills. They will be highly motivated, with a flexible
attitude; be able to work independently, whilst committed to work and learn as
part of a team. Above all, they will be dedicated to providing patients, their families,
and carers with proactive, joined-up and personalised care.
This role is intended to become an integral part of
the PCNs multidisciplinary team, which works alongside local village agents/social
prescribing link workers, other community health care teams, social care teams
and secondary care teams to provide a system-wide approach to personalised care.
The post-holder will be required to promote and embed a personalised care
approach across the PCN and contribute to the development of a local integrated
neighbourhood team (INT).
The role is a senior clinical role within the PCN. Supported
by the GP Clinical Lead for the Proactive Care Team and the Lead Nurses of the
five PCN GP surgeries, the postholder will be required to provide day-to-day clinical
supervision of, and clinical leadership for, the PCNs Community Health Care
Assistant. The post-holder may also be
required to be allocated as Lead Practitioner for some parts of the Proactive
Care Teams service(s) as the team, and its workstreams develop.
The job description and
person specification may be reviewed on an ongoing basis in accordance with the
changing needs of Taunton Central Primary Care Network and its GP member
practices.
Job description
Job responsibilities
The Community Complex Care Nurse will play a key role
within Taunton Central PCN, identifying and working with patients who would
benefit from proactive care, including but not limited to:
-
patients
living with moderate or severe frailty, or likely to become frail in next 10
years;
-
patients
experiencing health inequalities; and / or
-
patients
relying on unplanned care to manage their conditions
Where integrated community-based services could better
support those patients to manage their:
-
physical
and mental health needs;
-
social
care needs; and
-
self-care.
Supported by a multi-disciplinary team, the Community
Complex Care Nurse will have day-to-day responsibility for ensuring PCN
patients - who have been identified as appropriate for receiving the proactive model
of care, and allocated to them - receive:
-
An
holistic assessment to identify the patients health, social and self-care
needs and goals;
Personalised
care and support planning, to include but not limited to:
- collation of personalised, baseline and goals information.
- preparation of a Personalised Care and Support Plan
(PCSP); that plan to be regularly reviewed, updated and implemented to meet the
patients changing needs and goals; and
- subject to relevant training, preparation of a Treatment
Escalation Plan (TEP), if appropriate for the patient;
Multidisciplinary
working to address and meet the patients needs and goals, to include support
to navigate the care and support available to them across local health and care
services;
Co-ordinated
care, to include but not limited to:
- the promotion of self-care; and
- supporting patients to access the services and support
they require to understand and manage their own health and wellbeing (e.g.
making referrals village agents/social prescribing link workers, health and
wellbeing coaches, and other professionals as and when appropriate);
-
Intervention
and support at a level appropriate to their need and as identified as part of
their holistic assessment, personalised care and support planning and
multidisciplinary working.
The post-holder will work closely with patients usual
GPs, surgeries and the PCNs health care teams, to manage a caseload of
patients. They will act as the single point of contact for those teams, and
external health and social care providers, to ensure the appropriate support is
made available to their caseload of patients and their carers; supporting the
patients to understand and manage their condition and ensuring their changing
needs are addressed.
This is achieved by bringing together all the
information about a persons care and support needs and exploring options to
meet these within a single personalised care and support plan, based on what
matters to the person and through multidisciplinary and coordinated working, to
include self-management of needs by the patient at home.
The post-holder will be a dedicated, reliable and patient-focused
healthcare professional. They will enjoy working with a wide range of people, delivering
personalised care and the challenge, and rewards, of setting up and developing new
services. They will have excellent written and verbal communication skills, adopt
a holistic and personalised approach to care delivery, and have good organisational
and time management skills. They will be highly motivated, with a flexible
attitude; be able to work independently, whilst committed to work and learn as
part of a team. Above all, they will be dedicated to providing patients, their families,
and carers with proactive, joined-up and personalised care.
This role is intended to become an integral part of
the PCNs multidisciplinary team, which works alongside local village agents/social
prescribing link workers, other community health care teams, social care teams
and secondary care teams to provide a system-wide approach to personalised care.
The post-holder will be required to promote and embed a personalised care
approach across the PCN and contribute to the development of a local integrated
neighbourhood team (INT).
The role is a senior clinical role within the PCN. Supported
by the GP Clinical Lead for the Proactive Care Team and the Lead Nurses of the
five PCN GP surgeries, the postholder will be required to provide day-to-day clinical
supervision of, and clinical leadership for, the PCNs Community Health Care
Assistant. The post-holder may also be
required to be allocated as Lead Practitioner for some parts of the Proactive
Care Teams service(s) as the team, and its workstreams develop.
The job description and
person specification may be reviewed on an ongoing basis in accordance with the
changing needs of Taunton Central Primary Care Network and its GP member
practices.
Person Specification
Qualifications
Essential
- Registered General Nurse. Degree level education in related subject. Post basic qualification in relevant subject (e.g. long term condition(s) management). Level 3 Adult Safeguarding Training
Desirable
- Prescribing qualification. Recognised clinical leadership qualification or training. Recognised mentoring qualification or training
Experience
Essential
- Relevant post registration nursing experience at Band 6 or above in a related specialty (minimum 3 years)
- Experience of working with and supporting patients with (or likely to be experiencing) moderate or severe frailty
- Experience of working with and supporting patients relying on unplanned care to manage their conditions
- Evidence of autonomous working
- Experience of working in accordance with principles of shared-decision making
- Experience of multi-disciplinary professional working to include evidence of providing patient advice on accessing services and signposting to other services
- Evidence of effective communication skills
- Leadership and management experience
- Able to demonstrate a clear understanding of working with confidential information and an understanding of service user confidentiality
- Understanding of current issues facing the NHS and Social Care
- Understanding of health and social care processes
- Knowledge of local social services and community services structures
Desirable
- Experience of working with and supporting patients who have a learning disability
- Experience of working with and supporting patients experiencing health inequalities
- Experience of implementing a new patient service
- Prescribing experience
- Experience of using EMIS software
- Experience of using Ardens searches
- Experience of using risk stratification tool software (e.g., Brave AI)
Skills and Abilities
Essential
- Evidence of a good standard of literacy/English language skills
- Evidence of effective and excellent people skills
- Excellent written and verbal communication skills
- Ability to work in a multi-disciplinary setting where influence and negotiation is required
- Able to deal with service users sensitively
- IT Literate
Person Specification
Qualifications
Essential
- Registered General Nurse. Degree level education in related subject. Post basic qualification in relevant subject (e.g. long term condition(s) management). Level 3 Adult Safeguarding Training
Desirable
- Prescribing qualification. Recognised clinical leadership qualification or training. Recognised mentoring qualification or training
Experience
Essential
- Relevant post registration nursing experience at Band 6 or above in a related specialty (minimum 3 years)
- Experience of working with and supporting patients with (or likely to be experiencing) moderate or severe frailty
- Experience of working with and supporting patients relying on unplanned care to manage their conditions
- Evidence of autonomous working
- Experience of working in accordance with principles of shared-decision making
- Experience of multi-disciplinary professional working to include evidence of providing patient advice on accessing services and signposting to other services
- Evidence of effective communication skills
- Leadership and management experience
- Able to demonstrate a clear understanding of working with confidential information and an understanding of service user confidentiality
- Understanding of current issues facing the NHS and Social Care
- Understanding of health and social care processes
- Knowledge of local social services and community services structures
Desirable
- Experience of working with and supporting patients who have a learning disability
- Experience of working with and supporting patients experiencing health inequalities
- Experience of implementing a new patient service
- Prescribing experience
- Experience of using EMIS software
- Experience of using Ardens searches
- Experience of using risk stratification tool software (e.g., Brave AI)
Skills and Abilities
Essential
- Evidence of a good standard of literacy/English language skills
- Evidence of effective and excellent people skills
- Excellent written and verbal communication skills
- Ability to work in a multi-disciplinary setting where influence and negotiation is required
- Able to deal with service users sensitively
- IT Literate
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).
