Advanced Care Planning Practitioner

Job summary

We are seeking an experienced Advanced Care Planning Practitioner to work across the Wyre Forest Health Partnership (WFHP) PCN and multi-site GP Partnership, based at Church Street Surgery, with collaborative working across our other four sites at Stourport, Bewdley, Kidderminster Medical Centre and Hagley. This is a part time role at 30 hours per week.

The Advanced Care Planning (ACP) Nurse will be a prescriber able to lead advance care planning and annual holistic reviews for residents across nursing, residential and learning disability care homes.

This role is central to delivering high-quality, proactive, person-centred care in line with Enhanced Health in Care Homes (EHCH) requirements. The postholder will undertake complex annual reviews, support anticipatory care planning, and provide expert medication management, including prescribing responsibilities.

You will ensure that all new residents are offered an initial advance care planning review within six weeks of admission to a care home and that all residents receive an annual holistic healthcare needs review incorporating proactive care planning and medication optimisation.

Main duties of the job

• Undertake complex advance care planning discussions with residents and families, including end of life preferences and treatment escalation planning.
• Conduct annual holistic healthcare needs reviews, incorporating frailty assessment, dementia care planning, mental health review and long-term condition management.
• Act as an independent prescriber, responsible for - Medication optimisation, Deprescribing where appropriate, Prescribing anticipatory Just in Case (JIC) medications
• Complete and update ReSPECT forms, Treatment Escalation Plans (TEPs), and Advance Decisions to Refuse Treatment (ADRT).
• Document reviews using EMIS templates, including frailty scoring (Rockwood) and advanced care planning sections.
• Provide proactive, preventative care planning to reduce avoidable admissions and improve resident outcomes.
• Review advance care plans following hospital discharge where appropriate.
• Work closely with care coordinators, who will support long-term condition (LTC) reviews, ensuring clear delineation of responsibilities.
• Maintain continuity of care across the care home population.
• Contribute to EHCH delivery and compliance standards.
• Participate in care home MDT meetings and collaborative working with Neighbourhood Teams, Learning Disability Teams, Admiral Nurses and acute services.

About us

Wyre Forest Health Partnership (WFHP) www.wyreforesthealthpartnership.co.uk

Wyre Forest Health Partnership is a thriving, forward-thinking organisation, delivering high-quality and innovative patient care at scale. Our values care, commitment, and integrity are at the heart of everything we do.

Established in December 2014, WFHP operates as a single partnership across five sites. We provide care for approximately 73,000 patients and support a dedicated team of around 250 healthcare professionals, including 60 GPs. Our scale and integrated structure allow us to offer resilient, modern primary care with robust clinical and operational support.

We are committed to continuous improvement, constantly evolving to enhance the patient experience and streamline our services.

Sustainability is also a key priority. In line with the NHS's goal of achieving net zero greenhouse gas emissions, WFHP is actively working to reduce our environmental impact. We encourage every new team member to support this mission by embedding sustainable practices into their daily work.

Learn more at www.wyreforesthealthpartnership.co.uk.