Job summary
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
Main duties of the job
Core
responsibilities of the frailty nurse.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 general and specific health
screenings to the patients with referral to GPs as
necessary.
To ensure proactive and early case management of
frail patients with complex needs to prevent unnecessary hospital
admissions/readmissions.
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.
About us
Primary Care Networks (PCNs) were introduced into the NHS in 2019. Essentially, it is a group of GP Practices working together. They share resources and specialist staff, meaning each Practice and their patients benefit from additional services that individual practices couldn't provide independently.
The Outer West PCN is a collaboration between Newburn, Denton Turret, Denton Park, Throckley, Parkway and Westerhope GP surgeries in Newcastle upon Tyne. Oversight and management are provided by the Clinical Director and Board, alongside a dedicated PCN Project Manager.
The PCNs vision is to be a collaborative needs-led Network that has provided significant and demonstrable improvement to the health of our population
Job description
Job responsibilities
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 make a targeted clinical assessment of
patients with newly presenting minor illness and manage appropriately.
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.
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
Job description
Job responsibilities
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 make a targeted clinical assessment of
patients with newly presenting minor illness and manage appropriately.
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.
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
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
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).
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).