PCN Frailty Nurse

Job description

Job responsibilities

JOB DESCRIPTION

Job Title: PCN Frailty Nurse

Accountable to: Newcastle OW PCN Clinical Director and PCN Board

Reports to: Dr. Ian Morgan, PCN Clinical Director & frailty clinical lead, Newburn Surgery

Sarah Levinson, PCN Manager, Denton Park Health Centre

Location Denton Park Health Centre (base) with some time at the other five practices in OW PCN (Newburn, Throckley, Parkway, Denton Turret, Westerhope).

Plus travel to visit patients in homes.

Hours Part time, 30 hours (negotiable)

Summary of Role

The specific purpose of the post is to support and improve the health and wellbeing of our frail, housebound patients. This will have a focus on long-term medical conditions such as diabetes, hypertension, and cardiovascular disease, but will also aim to take a wider holistic view, including providing information, advice, or referrals to other services.

The post holder will work within a PCN frailty team including a health care assistant (HCA), social prescriber (SPLW) and a GP frailty lead but will also liaise closely with the clinicians at each of the practices within the OW Primary Care Network (PCN) and other members of the broader PCN team.

The clinical part of the role will primarily involve visiting patients in their own home, using a person-centred approach to undertake a comprehensive needs assessment. This will involve taking a detailed history and formulating a simple management plan based on this information together with the results of simple investigations (e.g. blood pressure and blood results) that have been performed in advance by the HCA. Such management will typically follow protocols and medical guidelines for the relevant conditions and will be guided by GP input when required.

The role does NOT involve the assessment and management of acutely unwell patients.

Primary responsibilities

The following are the core responsibilities of the frailty nurse. There may, on occasion, be a requirement to carry out other tasks dependent upon factors such as workload and staffing levels. For frail and housebound patients:

To visit patients at home as part of the OW PCN frailty team.

To make a comprehensive holistic assessment of health and wellbeing needs, including history taking and simple investigations.

To recognise situations that may be detrimental to the health and well-being of the individual and act on the findings.

To provide ongoing management of long-term conditions, such as diabetes, COPD, hypertension, and cardiovascular disease.

To support and advise patients on the promotion of health, prevention of ill-health and the self-management of their health within their own abilities.

To undertake comprehensive care planning including Emergency Health Care Planning (EHCP).

To provide nursing treatments to patients in participation with GPs or independently to agreed practice protocols.

To provide general and specific health screenings to the patients (within agreed protocols) with referral to GPs as necessary.

To provide appropriate signposting to a relevant clinician or external organisation (whilst ensuring that the patient receives appropriate ongoing care).

To ensure that all necessary arrangements are completed promptly and in a safe manner.

To ensure proactive and early case management of frail patients with complex needs to prevent unnecessary hospital admissions/readmissions.

To maintain clear, concise, and accurate documentation within the GP on-line systems provided (EMIS and SystemOne).

To communicate complex and sensitive information concerning a patients medical condition effectively to patients/carers, recognising that sometimes there are barriers to understanding.

To maintain effective communication with GP practice and other appropriate healthcare teams to the benefit of the patient.

To support the HCA and SPLW, providing guidance when necessary.

To work with and continually seek to develop the PCNs Frailty team.

To maintain knowledge of the context of the role and how this work seeks to meet Practice and PCN Obligations and Requirements.

To ensure that care given is supported by the best available evidence and local policies and procedures.

To maintain professional competency whilst remaining current and in date for NMC revalidation.

Secondary responsibilities

In addition to the primary responsibilities, the frailty nurse may be requested to:

Participate in audit work, effectively utilising the audit cycle

Participate in local initiatives to enhance service delivery and patient care

Support and participate in shared learning within the practice

Continually review clinical practices, responding to local and national policies and initiatives where appropriate

Participate in the review of significant and near-miss events applying a structured approach, i.e. root cause analysis (RCA)

Generic Responsibilities

All staff in the Outer West PCN Practices have a duty to conform to the following:

Person Specification

Qualifications

Essential

• Registered Nurse
• Experience of working in a primary care environment
• Experience of working as a practice nurse or community nurse
• Experience of chronic disease management
• Excellent communication skills (written and oral)
• Strong IT skills
• Clear, polite telephone manner
• Competent in the use of Office and Outlook
• EMIS and S1 user skills
• Effective time management (planning and organising)
• Ability to work as a team member and autonomously
• Good interpersonal skills
• Problem solving and analytical skills
• Ability to follow clinical policy and procedure
• Experience with audits
• Experience with clinical risk management

Desirable

• Post graduate diploma or degree (primary care)
• Independent prescriber
• Experience of working within a Primary Care Network or multi-site context.
• Knowledge of public health issues in the local area
• Awareness of issues within the wider health arena

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

Denton Park Medical Group

Address

Denton Park Health Centre

West Denton Way

Newcastle Upon Tyne

NE5 2QW

Employer's website

https://www.dentonparkmedicalgroup.co.uk (Opens in a new tab)