Job responsibilities
Administration
Maintaining efficient clerical and office systems and providing administrative support to the team.
Be the main point of contact for the PCN, dealing with all communication in a professional, helpful manner.
Supporting new staff with system access and induction.
Receiving and actioning referrals.
Overall responsibility for arranging the weekly PCN-led MDT meetings.
Manage the meeting agenda items and take minutes.
Identify the patients needing to be prioritised for review that week.
Ensure all new residents are reviewed in the MDT within four weeks of arrival.
Ensure all residents returning to the home after an acute hospital admission are reviewed by the MDT within seven days of return.
Circulate relevant information to MDT members in advance of the meeting.
Ensure actions from the MDT are recorded and care plans are correctly updated.
Liaise with all clinical and non-clinical members in the MDT to ensure effective MDT function.
Chase progress against actions and ensure follow-up where necessary.
Manage reporting required and associated within the PCN contract for Enhanced Health in Care Homes support.
Care planning
Ensure every resident has a co-produced comprehensive care plan created within seven days of arriving as a resident.
Use provided templates and tools to undertake core assessment elements for inclusion in the care plan.
Holistically bring together all of 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.
Identify those elements of the care plan which require specialist input (pharmacist, dietician, nurse, medic etc.) and ensure that these are completed in timely manner.
Ensure end of life plans are correctly recorded and where appropriate have been shared with family members.
Identify where technology can be utilised to support continued independence or to aid remote monitoring of health and wellbeing.
Communicate effectively and sensitively and use language appropriate to a patient and carer/relatives condition and level of understanding.
Effectively use all methods of communication and be aware of and manage barriers to care.
Stakeholder Relationships:
Work as part of the wider holistic team to provide cover and support as necessary.
To work with our clinical and digital system colleagues to implement and operate technology solutions which may include wearables or equipment to enable self-taking of health diagnostics e.g. blood pressure, weight etc.
Build and maintain relationships with internal and external staff; including care home staff and leads, GPs, pharmacists, community nursing team, therapists, dementia nurses etc.
As this is a new and evolving role, this is not an exhaustive list of duties and responsibilities, and the post holder may be required to undertake other duties that fall within the grade of the job, in discussion with their line manager.
The content of this job description will be reviewed regularly in the light of changing service requirements and any such changes will be discussed with the post holder.
Key working relationships
Local care homes
PCN EHCH Multi-Disciplinary Team
GP Practices within the PCN
Practice Leaders (Partners and Practice Managers)
PCN Therapists
PCN Specialist Nurse Practitioners
PCN Social Prescribers
PCN Clinical Pharmacists
PCN Clinical Directors and Business Manager
Integrated Care Board (ICB) and NHSE
Community Health Teams both physical and mental health
Local Authority
Local Neighbourhood Team
CONFIDENTIALITY
In the course of seeking treatment, patients entrust us with, or allow us to gather sensitive information in relation to their health and other matters. They do so in confidence and have the right to expect that staff will respect their privacy and act appropriately.
In the performance of the duties outlined in this job description, the post-holder may have access to confidential information relating to patients and their carers, practice staff, and other healthcare workers. They may also have access to information relating to the PCN as a business organisation. All such information from any source is to be regarded as strictly confidential.
Information relating to patients, carers, colleagues, other healthcare workers or the business of the PCN may only be divulged to authorised persons in accordance with the employing practice policies and procedures relating to confidentiality and the protection of personal and sensitive data.
EQUALITY AND DIVERSITY
The post-holder will support the equality, diversity and rights of patients, carers, and colleagues, to include:
- Acting in a way that recognises the importance of peoples rights, interpreting them in a way that is consistent with PCN and the member practices procedures and policies, and current legislation.
- Respecting the privacy, dignity, needs and beliefs of patients, carers, and colleagues.
- Behaving in a manner which is welcoming to and of the individual, is non-judgemental and respects their circumstances, feelings, priorities, and rights.
PERSONAL AND PROFESSIONAL DEVELOPMENT
The post-holder will participate in any training programme implemented by the PCN as part of this employment, with such training to include:
- Participation in an annual individual performance review, including taking responsibility for maintaining a record of their own personal and/or professional development.
- Participation in the PCN mandatory training programme.
- Taking responsibility for own development, learning and performance, demonstrating skills and activities to others who are undertaking similar work.
QUALITY
The post-holder will strive to maintain quality within the PCN and will:
- Alert other team members to issues of quality and risk.
- Assess own performance and take accountability for their own actions, either directly or under supervision.
- Contribute to the effectiveness of the team by reflecting on own and team activities and making suggestions on ways to improve and enhance the teams performance.
- Work effectively with individuals in other agencies to meet patients needs.
- Effectively manage own time, workload and resources.
COMMUNICATION
The post-holder should recognise the importance of effective communication within the team and will strive to:
- Communicate effectively with patients and carers.
- Recognise peoples needs for alternative methods of communication and respond accordingly.
- Communicate effectively with other team members.