Care Home Senior Nurse Band 6
This job is now closed
Job summary
The purpose of this role is to support the development of the Chronic Disease Management Service offered by the LSA PCN Care Home Team. This will include offering support and supervision to other staff, developing pathways and flow charts for CDM reviews and regularly monitoring/review patients.
The service combines a proactive approach to care for patients in care homes together with a reactive coponent in responding to requests from care home staff for advice and support in relation to the care of care home patients.
The applicant will require at least 2 years post registration experience, experience of implementing change in clinical practice and experience of clinical assessment and care planning.
Main duties of the job
The key responsibilities of this role will include:
To support the development and initiation of the Chronic Disease Management service to be offered by the LSA PCN Care Home Team
To develop pathways and flow charts for CDM reviews
To offer support and supervision to other staff
To provide expert assessment, diagnosis, treatment, and referral where appropriate for the identified patients within a care home setting.
To develop individualised care management plans (PCSP for the patients in close discussion with them and their careers, care home staff and GPs.)
To provide holistic assessment of health care needs for each patient in collaboration with the patient and care home staff. An individual care plan to be written following the assessment of both long- and short-term health care needs.
To support patients in a preventative manner to avoid unnecessary admission to hospital and where appropriate refer onward to other community/specialist services in the event of the patient requiring additional treatment or support.
Liaise with GPs, care home carers and community pharmacies to improve the care of identified patients within care homes.
Attend meetings, including multi-agency, to promote the use and value of clinical specialists within the nursing/care home, community environment.
About us
A Primary Care Network (PCN) enables the provision of proactive, accessible, co-ordinated and integrated primary and community care, improving outcomes for patients. They are formed around natural communities based on GP registered lists, serving populations of around 30,000 to 50,000.
The Lytham St Annes Primary Care Network includes 5 GP Practices, Holland House, Fernbank, Parcliffe, Poplar, and Ansdell, serving a population of approximately 53,000 registered patients.
The PCN serves a diverse population with relatively low derpivation with a complexity from an above average elderly population and above average residents in care homes.
Details
Date posted
24 July 2023
Pay scheme
Agenda for change
Band
Band 6
Salary
Depending on experience
Contract
Fixed term
Duration
12 months
Working pattern
Flexible working
Reference number
A3604-23-0001
Job locations
Lytham Primary Care Centre
Lytham
FY8 5DQ
Job description
Job responsibilities
To provide holistic assessment of health care needs for each patient in collaboration with the patient and care home staff. An individual care plan to be written following the assessment of both long- and short-term health care needs.
To support patients in a preventative manner to avoid unnecessary admission to hospital and where appropriate refer onward to other community/specialist services in the event of the patient requiring additional treatment or support.
To support staff in caring for patients at the end of their life who have made an explicit wish to die in their care home and facilitate the use of the gold standard framework.
To ensure a positive patient experience through safe and efficient and effective care, involving the patient and care home staff in the planning of their care.
To act as a point of contact, where appropriate for the care home staff when there is a request to see, treat or refer any patient whose health status has deteriorated. To refer patients to the GP practice where appropriate
To demonstrate competence and confidence to refer to GP, advanced nurse practitioner, care home pharmacist or other agencies as appropriate.
To act as a patient advocate as appropriate.
To be aware of Safeguarding Adult Policies and Procedures and implement as appropriate.
To regularly monitor/review patients and act rapidly should the patients condition deteriorate.
To co-ordinate and support the provision of end-of-life care for patients and their families/carers in collaboration with the District Nursing Teams and Specialist Care Teams as the need arises.
The post holders work will be managed, rather than supervised, using own initiative at all times.
Advise/ train care homes on all aspects of care, and work with multi-disciplinary care home team to improve the service provided to clients within the care home.
Provide appropriate information about the service offered to patients in care homes as a result of this post to enable evaluation of the service.
To report any incidents and near misses identified, through the appropriate channels according to practice policy.
To document all incidents, enquiries and action taken
To liaise closely with the key stakeholders at all times to advise and co-ordinate care provision.
To work with Out of Hours Service to ensure that there is care and support available for the patients if needed, 24 hours per days, 7 days per week.
To communicate complex clinical information in an understandable form to patients and carers to assist in their treatment.
To communicate information to patients, carers and care assistants and care home staff in an understandable form to ensure their co-operation in treatment.
To make clear decisions with confidence and communicate these decisions effectively.
The service combines a proactive approach to care for patients in care homes together with a reactive component in responding to requests from care home staff for advice and support in relation to the care of care home patients.
Use advanced communication skills, with due consideration to levels of comprehension and physical or mental disabilities, to facilitate the understanding and concordance of medicines management to patients and carers. Showing empathy when discussing medication with individual patients, bearing in mind their underlying condition and anxieties.
Communicate sensitive/contentious and occasionally highly complex medicine related information and advice to patients, carers, GPs and other members of the health care team.
Communicate on a variety of different levels depending on whether you are dealing with health professionals or patients. Information may be complex and require translation into a more patient friendly format.
Communicate sensitively with patients and carers about their medication there may be instances where there are emotional circumstances.
Communicate prescribing issues to relevant healthcare professionals within the practice team and within the hospital sector often using influencing/ negotiating skills with prescribers to promote evidence based, quality prescribing. Clinicians may have strong opposing views and your advice may be challenged.
Communication may involve one to one meetings or small group sessions and making presentations to appropriate groups. Communication may be written, via a letter or email or verbal, by telephone or in person.
Promote best practice in healthcare by applying a sound and detailed theoretical understanding of therapeutics, and evidence-based medicine.
Liaise with GPs, care home carers and community pharmacies to improve the care of identified patients within care homes.
Attend meetings, including multi-agency, to promote the use and value of clinical specialists within the nursing/care home, community environment.
Liaise with Care Home Managers to advise and support on Care Quality Commission (CQC) issues related to patient care.
Network with other care home nurses to share information and exchange ideas for developments to the service
Offer a strategic view relating to specialist nursing care within care homes and domiciliary care, to maintain and improve quality and standard of care for patients.
Continuously monitor the impact of the assessments and care undertaken in care homes/domiciliary care and their impact on GP practices.
Monitor the support provided for patients to remain in their own care setting, improving their health outcomes and quality of life.
Support the training and development of a range of health professionals and care staff in order to improve the safe care of patients.
Develop and share training resources to support best practice by clinical and non-clinical workers in the health and social care sectors
Facilitate the development and spread of good practice across the practices whilst minimising risk and encompassing clinical governance principles.
Provide information and advice to practice staff, care home staff and patients regarding safe and effective nursing care. This will necessitate the use of high level negotiating and influencing skills as information may on occasion need to be presented and may on occasion be of a contentious or highly complex nature.
Maintain a continuing development portfolio and be an up to date evidence based practitioner
Be able to critically appraise evidence e.g. clinical trials. This involves understanding, interpreting and assessing the data accurately to inform decisions and advice given
To develop and deliver agreed clinical audits and protocols for specific therapeutic areas.
To act responsibly in dealing with difficult situations and the consequences.
To recognise the importance of making appropriate and timely referrals, recognising ones own limitations and those of the team.
To work effectively with sound judgement when dealing with complex emotional situations and family dynamics.
To review patients notes and prescriptions and to provide specialised advice to patients, medical staff and other healthcare professionals, in order to ensure safe patient care the appropriateness of medicines use. This will include evaluating the patients clinical condition, planning appropriate interventions, agreeing best outcome in partnership with the patient and agreeing an action plan with the doctors.
To work with the care homes team to develop and implement an agreed Risk Stratification for managing the caseload and service.
Assist in developing appropriate care pathways and associated protocols of care for patients on the caseload.
To regularly audit the caseload and feedback audit outcomes to the service manager
To collect and collate qualitative and quantitative data to enable evaluation of service and plan future developments.
To continuously work to improve the service for patients and their carers.
To undertake chronic disease management as a prescriber (following completion of any necessary training to the neighbourhood population To report adverse drug reactions (ADR) to the MHRA using the yellow card scheme
To ensure that any drug recalls/ alerts are actioned, including discussion with the relevant medical staff and informing patients as necessary.
To provide advice on medication and prescribing related clinical incidents.
Work with care homes and practices to develop patient information and systems to improve monitoring of patients on key drugs as well as proactive advice regarding individual patients treatment, particularly regarding those on complex medication regimens.
Assess patient needs through effective planning, implement and evaluate care according to individualised patient needs. Ensure that all patient computer records are maintained correctly.
Recognise when patient presentation requires referral onto other health professional or specialist teams and take appropriate actions.
To work across traditional boundaries to promote a seamless transfer of care.
To maintain accurate and contemporaneous documentation both electronic and paper to ensure timely and effective communication.
To maintain records/documentation in accordance with Trust policy and that of NMC standards for record keeping.
To be aware of the Data Protection Act to ensure appropriate action is taken to ensure patient confidentiality and protection of patient information
Act on own professional judgement on a daily basis with regard to making recommendations in respect of medicines management.
To work as a nurse within the practices and, typically within defined local protocols that have been approved by GPs.
Plan and prioritise own workload within each practice to ensure an equitable service across all designated Practices.
Job description
Job responsibilities
To provide holistic assessment of health care needs for each patient in collaboration with the patient and care home staff. An individual care plan to be written following the assessment of both long- and short-term health care needs.
To support patients in a preventative manner to avoid unnecessary admission to hospital and where appropriate refer onward to other community/specialist services in the event of the patient requiring additional treatment or support.
To support staff in caring for patients at the end of their life who have made an explicit wish to die in their care home and facilitate the use of the gold standard framework.
To ensure a positive patient experience through safe and efficient and effective care, involving the patient and care home staff in the planning of their care.
To act as a point of contact, where appropriate for the care home staff when there is a request to see, treat or refer any patient whose health status has deteriorated. To refer patients to the GP practice where appropriate
To demonstrate competence and confidence to refer to GP, advanced nurse practitioner, care home pharmacist or other agencies as appropriate.
To act as a patient advocate as appropriate.
To be aware of Safeguarding Adult Policies and Procedures and implement as appropriate.
To regularly monitor/review patients and act rapidly should the patients condition deteriorate.
To co-ordinate and support the provision of end-of-life care for patients and their families/carers in collaboration with the District Nursing Teams and Specialist Care Teams as the need arises.
The post holders work will be managed, rather than supervised, using own initiative at all times.
Advise/ train care homes on all aspects of care, and work with multi-disciplinary care home team to improve the service provided to clients within the care home.
Provide appropriate information about the service offered to patients in care homes as a result of this post to enable evaluation of the service.
To report any incidents and near misses identified, through the appropriate channels according to practice policy.
To document all incidents, enquiries and action taken
To liaise closely with the key stakeholders at all times to advise and co-ordinate care provision.
To work with Out of Hours Service to ensure that there is care and support available for the patients if needed, 24 hours per days, 7 days per week.
To communicate complex clinical information in an understandable form to patients and carers to assist in their treatment.
To communicate information to patients, carers and care assistants and care home staff in an understandable form to ensure their co-operation in treatment.
To make clear decisions with confidence and communicate these decisions effectively.
The service combines a proactive approach to care for patients in care homes together with a reactive component in responding to requests from care home staff for advice and support in relation to the care of care home patients.
Use advanced communication skills, with due consideration to levels of comprehension and physical or mental disabilities, to facilitate the understanding and concordance of medicines management to patients and carers. Showing empathy when discussing medication with individual patients, bearing in mind their underlying condition and anxieties.
Communicate sensitive/contentious and occasionally highly complex medicine related information and advice to patients, carers, GPs and other members of the health care team.
Communicate on a variety of different levels depending on whether you are dealing with health professionals or patients. Information may be complex and require translation into a more patient friendly format.
Communicate sensitively with patients and carers about their medication there may be instances where there are emotional circumstances.
Communicate prescribing issues to relevant healthcare professionals within the practice team and within the hospital sector often using influencing/ negotiating skills with prescribers to promote evidence based, quality prescribing. Clinicians may have strong opposing views and your advice may be challenged.
Communication may involve one to one meetings or small group sessions and making presentations to appropriate groups. Communication may be written, via a letter or email or verbal, by telephone or in person.
Promote best practice in healthcare by applying a sound and detailed theoretical understanding of therapeutics, and evidence-based medicine.
Liaise with GPs, care home carers and community pharmacies to improve the care of identified patients within care homes.
Attend meetings, including multi-agency, to promote the use and value of clinical specialists within the nursing/care home, community environment.
Liaise with Care Home Managers to advise and support on Care Quality Commission (CQC) issues related to patient care.
Network with other care home nurses to share information and exchange ideas for developments to the service
Offer a strategic view relating to specialist nursing care within care homes and domiciliary care, to maintain and improve quality and standard of care for patients.
Continuously monitor the impact of the assessments and care undertaken in care homes/domiciliary care and their impact on GP practices.
Monitor the support provided for patients to remain in their own care setting, improving their health outcomes and quality of life.
Support the training and development of a range of health professionals and care staff in order to improve the safe care of patients.
Develop and share training resources to support best practice by clinical and non-clinical workers in the health and social care sectors
Facilitate the development and spread of good practice across the practices whilst minimising risk and encompassing clinical governance principles.
Provide information and advice to practice staff, care home staff and patients regarding safe and effective nursing care. This will necessitate the use of high level negotiating and influencing skills as information may on occasion need to be presented and may on occasion be of a contentious or highly complex nature.
Maintain a continuing development portfolio and be an up to date evidence based practitioner
Be able to critically appraise evidence e.g. clinical trials. This involves understanding, interpreting and assessing the data accurately to inform decisions and advice given
To develop and deliver agreed clinical audits and protocols for specific therapeutic areas.
To act responsibly in dealing with difficult situations and the consequences.
To recognise the importance of making appropriate and timely referrals, recognising ones own limitations and those of the team.
To work effectively with sound judgement when dealing with complex emotional situations and family dynamics.
To review patients notes and prescriptions and to provide specialised advice to patients, medical staff and other healthcare professionals, in order to ensure safe patient care the appropriateness of medicines use. This will include evaluating the patients clinical condition, planning appropriate interventions, agreeing best outcome in partnership with the patient and agreeing an action plan with the doctors.
To work with the care homes team to develop and implement an agreed Risk Stratification for managing the caseload and service.
Assist in developing appropriate care pathways and associated protocols of care for patients on the caseload.
To regularly audit the caseload and feedback audit outcomes to the service manager
To collect and collate qualitative and quantitative data to enable evaluation of service and plan future developments.
To continuously work to improve the service for patients and their carers.
To undertake chronic disease management as a prescriber (following completion of any necessary training to the neighbourhood population To report adverse drug reactions (ADR) to the MHRA using the yellow card scheme
To ensure that any drug recalls/ alerts are actioned, including discussion with the relevant medical staff and informing patients as necessary.
To provide advice on medication and prescribing related clinical incidents.
Work with care homes and practices to develop patient information and systems to improve monitoring of patients on key drugs as well as proactive advice regarding individual patients treatment, particularly regarding those on complex medication regimens.
Assess patient needs through effective planning, implement and evaluate care according to individualised patient needs. Ensure that all patient computer records are maintained correctly.
Recognise when patient presentation requires referral onto other health professional or specialist teams and take appropriate actions.
To work across traditional boundaries to promote a seamless transfer of care.
To maintain accurate and contemporaneous documentation both electronic and paper to ensure timely and effective communication.
To maintain records/documentation in accordance with Trust policy and that of NMC standards for record keeping.
To be aware of the Data Protection Act to ensure appropriate action is taken to ensure patient confidentiality and protection of patient information
Act on own professional judgement on a daily basis with regard to making recommendations in respect of medicines management.
To work as a nurse within the practices and, typically within defined local protocols that have been approved by GPs.
Plan and prioritise own workload within each practice to ensure an equitable service across all designated Practices.
Person Specification
Other
Essential
- Clearly spoken
- Confident decision maker
- Able to take responsibility for own actions
- Willing to undertake any necessary training
- Able to work under pressure
- Demonstrable commitment to professional development
- Access to a suitable vehicle to be used within your role subject to the provision of the DDA.
Desirable
- Enthusiastic about working with older people
Skills
Essential
- Ability to use IT confidently and efficiently
- Excellent communication skills
- Good clinical knowledge
- Effective team member
- Dependable
- Able to prioritise work to deadlines
- Ability to work on own Initiative and as a member of a Team
- Must be able to demonstrate the need for confidentiality
- Ability to gain the confidence and credibility of a range of professionals
- Ability to be challenged and respond calmly
- Excellent interpersonal skills
- Ability to work to challenging deadlines
- Problem solving skills
Desirable
- Experience of working in partnership with a range of health and social care professionals
- Awareness of the national and local NHS priorities
Qualifications
Essential
- Nursing registration with NMC
- Educated to degree level or equivalent
- Clinical skills module for assessing diagnosing and treatment for unscheduled care
- Evidence of continuing professional development in relation to chronic disease management
- CPR and Anaphylaxis Update
- Education on Interpretation of blood results
Desirable
- Including but not fully inclusive hypertension, Rheumatology monitoring, Asthma, COPD, CHD, CVD, LVSD, Diabetes
Experience
Essential
- At least 2 years post registration experience
- Experience of implementing change in clinical practice
- Experience of clinical assessment and care planning.
- Excellent clinical knowledge of end of life, mental health, dementia, falls and fractures
- Excellent knowledge of adult safeguarding legislation, including MCA, DOLS, best interests decisions, advanced care planning
Desirable
- Experience of providing clinical advice within a care home setting
- Experience of working within a multidisciplinary team
- Experience of working in primary care
- Knowledge of general practice systems and community services
Person Specification
Other
Essential
- Clearly spoken
- Confident decision maker
- Able to take responsibility for own actions
- Willing to undertake any necessary training
- Able to work under pressure
- Demonstrable commitment to professional development
- Access to a suitable vehicle to be used within your role subject to the provision of the DDA.
Desirable
- Enthusiastic about working with older people
Skills
Essential
- Ability to use IT confidently and efficiently
- Excellent communication skills
- Good clinical knowledge
- Effective team member
- Dependable
- Able to prioritise work to deadlines
- Ability to work on own Initiative and as a member of a Team
- Must be able to demonstrate the need for confidentiality
- Ability to gain the confidence and credibility of a range of professionals
- Ability to be challenged and respond calmly
- Excellent interpersonal skills
- Ability to work to challenging deadlines
- Problem solving skills
Desirable
- Experience of working in partnership with a range of health and social care professionals
- Awareness of the national and local NHS priorities
Qualifications
Essential
- Nursing registration with NMC
- Educated to degree level or equivalent
- Clinical skills module for assessing diagnosing and treatment for unscheduled care
- Evidence of continuing professional development in relation to chronic disease management
- CPR and Anaphylaxis Update
- Education on Interpretation of blood results
Desirable
- Including but not fully inclusive hypertension, Rheumatology monitoring, Asthma, COPD, CHD, CVD, LVSD, Diabetes
Experience
Essential
- At least 2 years post registration experience
- Experience of implementing change in clinical practice
- Experience of clinical assessment and care planning.
- Excellent clinical knowledge of end of life, mental health, dementia, falls and fractures
- Excellent knowledge of adult safeguarding legislation, including MCA, DOLS, best interests decisions, advanced care planning
Desirable
- Experience of providing clinical advice within a care home setting
- Experience of working within a multidisciplinary team
- Experience of working in primary care
- Knowledge of general practice systems and community services
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
Lytham St Anne’s Primary Care Network
Address
Lytham Primary Care Centre
Lytham
FY8 5DQ
Employer's website
Employer details
Employer name
Lytham St Anne’s Primary Care Network
Address
Lytham Primary Care Centre
Lytham
FY8 5DQ
Employer's website
Employer contact details
For questions about the job, contact:
Details
Date posted
24 July 2023
Pay scheme
Agenda for change
Band
Band 6
Salary
Depending on experience
Contract
Fixed term
Duration
12 months
Working pattern
Flexible working
Reference number
A3604-23-0001
Job locations
Lytham Primary Care Centre
Lytham
FY8 5DQ
Supporting documents
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