Torquay Primary Care Network

Long-Term Conditions Visiting Practice Nurse

The closing date is 20 February 2026

Job summary

JOB PURPOSE

To provide a high-quality, patient-centred long-term condition service to housebound patients and patients residing in residential and nursing homes across Torquay Primary Care Network.

The role focuses on the proactive management of long-term conditions through annual reviews, care planning, health promotion and preventative care, contributing to improved patient outcomes, reduced health inequalities and compliance with QOF and enhanced service requirements within the NHS.

Main duties of the job

KEY RESPONSIBILITIES

Clinical Responsibilities Visiting Service

In addition to the full scope of Practice Nurse duties, the post holder will:

  • Undertake home-based and care-home-based QOF reviews for patients with long-term conditions includingDiabetes,Asthma, COPD, Hypertension, Coronary Heart Disease (CHD), Dementia, Mental health conditions
  • Complete learning disability annual health checks in patients place of residence.
  • Undertake mental health annual reviews in line with national and local guidance.
  • Provide home-based vaccinations, including seasonal influenza and other vaccinations in line with PGDs.
  • Develop, update and review personalised care plans following clinical assessments.
  • Identify deterioration or unmet needs and escalate appropriately to GPs or community services.
  • Promote self-management, lifestyle modification and health education for patients and carers.

About us

Torquay PCN -Brunel Medical Practice, Southover Medical Practice, Chelston Hall Surgery and Croft Hall Medical Practice

Details

Date posted

22 January 2026

Pay scheme

Other

Salary

£41,000 a year

Contract

Permanent

Working pattern

Full-time

Reference number

A3299-26-0000

Job locations

Croft Hall Medical Practice

19 Croft Road

Torquay

TQ2 5UA


Chelston Hall Surgery

Old Mill Road

Torquay

TQ2 6HW


Brunel Medical Practice

St. Albans Road

Torquay

TQ1 3SL


Southover Medical Practice

Bronshill Road

Torquay

TQ1 3HD


Job description

Job responsibilities

Clinical Responsibilities Visiting Service

In addition to the full scope of Practice Nurse duties, the post holder will:

  • Undertake home-based and care-home-based QOF reviews for patients with long-term conditions including:
  • Diabetes
  1. Asthma
  2. COPD
  3. Hypertension
  4. Coronary Heart Disease (CHD)
  5. Dementia
  6. Mental health conditions

  • Complete learning disability annual health checks in patients place of residence.
  • Undertake mental health annual reviews in line with national and local guidance.
  • Provide home-based vaccinations, including seasonal influenza and other vaccinations in line with PGDs.
  • Develop, update and review personalised care plans following clinical assessments.
  • Identify deterioration or unmet needs and escalate appropriately to GPs or community services.
  • Promote self-management, lifestyle modification and health education for patients and carers.
Practice Nurse Clinical Responsibilities

  • The post holder will maintain full competence in Practice Nurse duties, including:
  • Assessment, planning, implementation and evaluation of patient care.
  • Recording and monitoring:
  • Height, weight, BMI
  • Blood pressure, pulse, respiration, temperature
  • Pulse oximetry
  • Urinalysis
  • ECG recording
  • Phlebotomy and specimen handling
  • Wound care and dressings
  • General injections and immunisations (including flu and pneumococcal)
  • Health promotion and lifestyle advice
  • Telephone advice and triage
  • Accurate and timely electronic documentation using clinical systems with appropriate coding, recalls and GMS/QOF data entry.

Extended Clinical Responsibilities

  • Diabetic interim and annual reviews in line with practice protocols.
  • Asthma and COPD annual reviews in line with practice guidelines.
  • Mental health annual review checks.
  • Depo-Provera administration.
  • Doppler assessments (under supervision of the Lead Nurse).
  • Strict adherence to infection prevention and control policies.

Medicines Management

  • Administer medicines and vaccinations safely in accordance with PGDs, PSDs and cold-chain requirements.
  • Identify issues relating to concordance, side effects and polypharmacy and escalate as required.
  • Work collaboratively with GPs, pharmacists and the wider MDT to optimise medicines management.

Safeguarding Responsibilities

  • Recognise, respond to and escalate safeguarding concerns relating to adults at risk and children.
  • Work in accordance with safeguarding legislation, local safeguarding policies and practice procedures.
  • Maintain mandatory safeguarding training appropriate to the role.

Lone Working and Personal Safety

  • Adhere to lone-working policies and personal safety procedures at all times.
  • Undertake dynamic risk assessments before and during home visits.
  • Use agreed check-in/check-out systems and report incidents, near misses or safety concerns promptly.

Multidisciplinary & Integrated Working

  • Work collaboratively with GPs, community nursing teams, social care, care-home staff and other agencies.
  • Participate in MDT discussions and contribute to holistic patient care planning.
  • Support anticipatory care, frailty management and admission avoidance initiatives.

Quality, Governance and Audit

  • Contribute to clinical audit, quality improvement and service development initiatives.
  • Participate in clinical governance meetings, significant event analysis and learning reviews.
  • Maintain high standards of care, identifying risks and contributing to continuous improvement.

Communication and Working Relationships

  • Communicate effectively and compassionately with patients, relatives and carers, including when conveying unwelcome news.
  • Maintain effective professional relationships with colleagues across the PCN and wider health and social care system.
  • Provide education and support to patients and colleagues within agreed competencies.

Confidentiality and Data Protection

  • Maintain strict confidentiality of patient, staff and business information.
  • Handle personal and sensitive data in accordance with data protection legislation, practice policies and professional standards.

Health & Safety

  • Promote and maintain health, safety and security for self and others.
  • Use infection control measures appropriately.
  • Identify, report and manage risks in the working environment.

Equality, Diversity and Inclusion

  • Act in accordance with equality legislation and practice policies.
  • Treat all patients, carers and colleagues with dignity, respect and fairness.
  • Deliver non-judgemental, inclusive care tailored to individual needs.

Personal and Professional Development

  • Maintain professional registration and undertake continuous professional development.
  • Participate in annual appraisal and performance review.
  • Take responsibility for maintaining and evidencing competence and development.

Job description

Job responsibilities

Clinical Responsibilities Visiting Service

In addition to the full scope of Practice Nurse duties, the post holder will:

  • Undertake home-based and care-home-based QOF reviews for patients with long-term conditions including:
  • Diabetes
  1. Asthma
  2. COPD
  3. Hypertension
  4. Coronary Heart Disease (CHD)
  5. Dementia
  6. Mental health conditions

  • Complete learning disability annual health checks in patients place of residence.
  • Undertake mental health annual reviews in line with national and local guidance.
  • Provide home-based vaccinations, including seasonal influenza and other vaccinations in line with PGDs.
  • Develop, update and review personalised care plans following clinical assessments.
  • Identify deterioration or unmet needs and escalate appropriately to GPs or community services.
  • Promote self-management, lifestyle modification and health education for patients and carers.
Practice Nurse Clinical Responsibilities

  • The post holder will maintain full competence in Practice Nurse duties, including:
  • Assessment, planning, implementation and evaluation of patient care.
  • Recording and monitoring:
  • Height, weight, BMI
  • Blood pressure, pulse, respiration, temperature
  • Pulse oximetry
  • Urinalysis
  • ECG recording
  • Phlebotomy and specimen handling
  • Wound care and dressings
  • General injections and immunisations (including flu and pneumococcal)
  • Health promotion and lifestyle advice
  • Telephone advice and triage
  • Accurate and timely electronic documentation using clinical systems with appropriate coding, recalls and GMS/QOF data entry.

Extended Clinical Responsibilities

  • Diabetic interim and annual reviews in line with practice protocols.
  • Asthma and COPD annual reviews in line with practice guidelines.
  • Mental health annual review checks.
  • Depo-Provera administration.
  • Doppler assessments (under supervision of the Lead Nurse).
  • Strict adherence to infection prevention and control policies.

Medicines Management

  • Administer medicines and vaccinations safely in accordance with PGDs, PSDs and cold-chain requirements.
  • Identify issues relating to concordance, side effects and polypharmacy and escalate as required.
  • Work collaboratively with GPs, pharmacists and the wider MDT to optimise medicines management.

Safeguarding Responsibilities

  • Recognise, respond to and escalate safeguarding concerns relating to adults at risk and children.
  • Work in accordance with safeguarding legislation, local safeguarding policies and practice procedures.
  • Maintain mandatory safeguarding training appropriate to the role.

Lone Working and Personal Safety

  • Adhere to lone-working policies and personal safety procedures at all times.
  • Undertake dynamic risk assessments before and during home visits.
  • Use agreed check-in/check-out systems and report incidents, near misses or safety concerns promptly.

Multidisciplinary & Integrated Working

  • Work collaboratively with GPs, community nursing teams, social care, care-home staff and other agencies.
  • Participate in MDT discussions and contribute to holistic patient care planning.
  • Support anticipatory care, frailty management and admission avoidance initiatives.

Quality, Governance and Audit

  • Contribute to clinical audit, quality improvement and service development initiatives.
  • Participate in clinical governance meetings, significant event analysis and learning reviews.
  • Maintain high standards of care, identifying risks and contributing to continuous improvement.

Communication and Working Relationships

  • Communicate effectively and compassionately with patients, relatives and carers, including when conveying unwelcome news.
  • Maintain effective professional relationships with colleagues across the PCN and wider health and social care system.
  • Provide education and support to patients and colleagues within agreed competencies.

Confidentiality and Data Protection

  • Maintain strict confidentiality of patient, staff and business information.
  • Handle personal and sensitive data in accordance with data protection legislation, practice policies and professional standards.

Health & Safety

  • Promote and maintain health, safety and security for self and others.
  • Use infection control measures appropriately.
  • Identify, report and manage risks in the working environment.

Equality, Diversity and Inclusion

  • Act in accordance with equality legislation and practice policies.
  • Treat all patients, carers and colleagues with dignity, respect and fairness.
  • Deliver non-judgemental, inclusive care tailored to individual needs.

Personal and Professional Development

  • Maintain professional registration and undertake continuous professional development.
  • Participate in annual appraisal and performance review.
  • Take responsibility for maintaining and evidencing competence and development.

Person Specification

Skills and Abilities

Essential

  • Excellent communication and interpersonal skills
  • Ability to work autonomously and manage own workload
  • High standard of electronic record-keeping and IT literacy
  • Ability to work effectively as part of a multidisciplinary team

Other Requirements

Essential

  • Full UK driving licence
  • Access to own vehicle with appropriate business-use insurance
  • Ability to travel between practice sites and patient homes
  • Willingness to undertake mandatory and role-specific training

Qualifications

Essential

  • Registered General Nurse (RGN)
  • Current NMC registration

Desirable

  • Diploma or Degree in Practice Nursing
  • Non-medical prescribing qualification (V300) or willingness to train

Experience

Essential

  • Experience in managing long-term conditions including asthma, diabetes, COPD, hypertension, CHD and mental health
  • Experience of undertaking annual health reviews
  • Understanding of QOF and chronic disease management frameworks
  • Knowledge of safeguarding principles

Desirable

  • Experience working with housebound or care-home populations
  • Experience in frailty, dementia or end-of-life care
  • Teaching, mentoring or audit experience
Person Specification

Skills and Abilities

Essential

  • Excellent communication and interpersonal skills
  • Ability to work autonomously and manage own workload
  • High standard of electronic record-keeping and IT literacy
  • Ability to work effectively as part of a multidisciplinary team

Other Requirements

Essential

  • Full UK driving licence
  • Access to own vehicle with appropriate business-use insurance
  • Ability to travel between practice sites and patient homes
  • Willingness to undertake mandatory and role-specific training

Qualifications

Essential

  • Registered General Nurse (RGN)
  • Current NMC registration

Desirable

  • Diploma or Degree in Practice Nursing
  • Non-medical prescribing qualification (V300) or willingness to train

Experience

Essential

  • Experience in managing long-term conditions including asthma, diabetes, COPD, hypertension, CHD and mental health
  • Experience of undertaking annual health reviews
  • Understanding of QOF and chronic disease management frameworks
  • Knowledge of safeguarding principles

Desirable

  • Experience working with housebound or care-home populations
  • Experience in frailty, dementia or end-of-life care
  • Teaching, mentoring or audit experience

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).

Employer details

Employer name

Torquay Primary Care Network

Address

Croft Hall Medical Practice

19 Croft Road

Torquay

TQ2 5UA

Employer details

Employer name

Torquay Primary Care Network

Address

Croft Hall Medical Practice

19 Croft Road

Torquay

TQ2 5UA

Employer contact details

For questions about the job, contact:

Joe Griffiths

joe.griffiths@nhs.net

Details

Date posted

22 January 2026

Pay scheme

Other

Salary

£41,000 a year

Contract

Permanent

Working pattern

Full-time

Reference number

A3299-26-0000

Job locations

Croft Hall Medical Practice

19 Croft Road

Torquay

TQ2 5UA


Chelston Hall Surgery

Old Mill Road

Torquay

TQ2 6HW


Brunel Medical Practice

St. Albans Road

Torquay

TQ1 3SL


Southover Medical Practice

Bronshill Road

Torquay

TQ1 3HD


Supporting documents

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