Job summary
to enhance frailty care for our elderly practice population, working closely with practice staff and allied professionals.
Participate in the care and development of anticipatory and current care planning for the practice., to include treatment, preventative care, screening, future planning and patient education in the practice and also in our care homes.
To act as a focal point of communication between patients, doctors, nurses and other members of the primary health care team within the practice and the community.
To act as liaison between patients, their families, GP's and other members of the team.
Main duties of the job
The fundamental role of the post holder is to meet the primary care needs of an identified group of people identified as frail and needing further support in the community. The post holder will liaise with other community health and social care providers to meet the identified needs of these patients. This workload will involve reviewing medical issues and current problems, completing medication reviews and dementia screening, developing a treatment escalation plan, ensuring all appropriate assessments are completed and developing and implementing an appropriate individualised plan of care.
The service is designed to achieve the following:
- A fall in ambulance hospital journeys required by residents
- A drop in hospital attendances for these residents
- A reduction in hospital admissions for these residents
- Improved Health and social care support for these residents and their carers to help them to keep at home and avoid hospital admission.
- Joined up pathways with acute trust, ambulance service, community services, social services, community voluntary services and end of life care to support admission avoidance.
About us
Well Close Medical Group is part of Lindisfarne health and also Well Up North Primary Care network.
we have just over 9000 patients but a higher than average elderly population. we look after 5 local care homes which have around 150 patients residing in them.
Job description
Job responsibilities
- To assess, plan, implement and evaluate specialist treatment and care through personalised care plans to people on an allocated caseload; promoting independence and autonomy; working within a multi-disciplinary team.
- Supporting the GP in improving diagnosis and screening of people with dementia within the care home, this will be by the review of all care home residents.
- Advance own clinical knowledge, skill and competence based on current evidence through advanced educational programmes.
- Completing and sharing advanced care plans
- Partnership working with other providers to deliver seamless joined up care.
- Reviewing and making clinical decisions, including prioritisation of need.
- Provide highly specialist advice to others regarding the management and care of patients/service users.
- To demonstrate clinical effectiveness by use of evidence-based practice and outcome measures.
- Recognise, assess, and manage risk across the immediate and wider working environment and make appropriate decisions autonomously, ensuring statutory requirements are met.
- To be responsible for patient safety through knowledge of systems, legal requirements and understanding of litigation.
- To communicate effectively in verbal and written form in the exchange of highly complex, sensitive or contentious information in difficult situations using de-escalation, mediation, resolution and professional Duty of Candour.
- To evaluate care, taking appropriate action leading to improvement in quality standards through clinical audit, root cause analysis and dealing with complaints.
- Provision of support to carers considering what can put in place to support that persons mental health and wellbeing, by the use of tools to identify deterioration in wellbeing and mental state.
- Liaison between local organisations such as volunteering etc to provide services that can support the delivery of care within the patients own home.
- Referral to and attendance at MDTs involving a range of health and care professionals, from one or more organisations, working together to deliver comprehensive patient care. The benefits of such an approach can include improved health outcomes, enhanced satisfaction for the individual and a more efficient use of resources.
Job description
Job responsibilities
- To assess, plan, implement and evaluate specialist treatment and care through personalised care plans to people on an allocated caseload; promoting independence and autonomy; working within a multi-disciplinary team.
- Supporting the GP in improving diagnosis and screening of people with dementia within the care home, this will be by the review of all care home residents.
- Advance own clinical knowledge, skill and competence based on current evidence through advanced educational programmes.
- Completing and sharing advanced care plans
- Partnership working with other providers to deliver seamless joined up care.
- Reviewing and making clinical decisions, including prioritisation of need.
- Provide highly specialist advice to others regarding the management and care of patients/service users.
- To demonstrate clinical effectiveness by use of evidence-based practice and outcome measures.
- Recognise, assess, and manage risk across the immediate and wider working environment and make appropriate decisions autonomously, ensuring statutory requirements are met.
- To be responsible for patient safety through knowledge of systems, legal requirements and understanding of litigation.
- To communicate effectively in verbal and written form in the exchange of highly complex, sensitive or contentious information in difficult situations using de-escalation, mediation, resolution and professional Duty of Candour.
- To evaluate care, taking appropriate action leading to improvement in quality standards through clinical audit, root cause analysis and dealing with complaints.
- Provision of support to carers considering what can put in place to support that persons mental health and wellbeing, by the use of tools to identify deterioration in wellbeing and mental state.
- Liaison between local organisations such as volunteering etc to provide services that can support the delivery of care within the patients own home.
- Referral to and attendance at MDTs involving a range of health and care professionals, from one or more organisations, working together to deliver comprehensive patient care. The benefits of such an approach can include improved health outcomes, enhanced satisfaction for the individual and a more efficient use of resources.
Person Specification
experience
Essential
- experience of working in accordance with the NMC Code of professional Conduct (2002) and The Scope of professional Practice (1992) or equivalent.
- experience of Microsoft Office software
- experience of dealing with the public / patients
- completing personalised care plans
Desirable
- experience of System One and Ardens
- experience of working within a Primary Care MDT
- experience of working within geriatric medicine
- liaising with local organisations and other agencies.
Qualifications
Essential
- Registered general Nurse
- qualified prescriber
- a demonstrable commitment to professional development
- Qualifications / certificates or equivalent in wound management, adult vaccinations and immunisations and phlebotomy.
- experience in elderly medicine
Desirable
- qualifications / certificates in long term condition management.
qualities and attributes
Essential
- Able to demonstrate enthusiasm to develop nursing skills.
- an understanding, acceptance and adherence to the need for strict confidentiality
- ability to use own judgement, resourcefulness and common sense
- ability to work without direct supervision and determine own workload priorities
- ability to work as part of an integrated multi skilled team
- pleasant and articulate
- able to work under pressure
- able to work in a changing environment
- a desire to improve care for elderly patients
Person Specification
experience
Essential
- experience of working in accordance with the NMC Code of professional Conduct (2002) and The Scope of professional Practice (1992) or equivalent.
- experience of Microsoft Office software
- experience of dealing with the public / patients
- completing personalised care plans
Desirable
- experience of System One and Ardens
- experience of working within a Primary Care MDT
- experience of working within geriatric medicine
- liaising with local organisations and other agencies.
Qualifications
Essential
- Registered general Nurse
- qualified prescriber
- a demonstrable commitment to professional development
- Qualifications / certificates or equivalent in wound management, adult vaccinations and immunisations and phlebotomy.
- experience in elderly medicine
Desirable
- qualifications / certificates in long term condition management.
qualities and attributes
Essential
- Able to demonstrate enthusiasm to develop nursing skills.
- an understanding, acceptance and adherence to the need for strict confidentiality
- ability to use own judgement, resourcefulness and common sense
- ability to work without direct supervision and determine own workload priorities
- ability to work as part of an integrated multi skilled team
- pleasant and articulate
- able to work under pressure
- able to work in a changing environment
- a desire to improve care for elderly patients
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).