PCN Ageing Well Nurse Practitioner

Job responsibilities

• Undertake clinical nursing practice using expert knowledge and clinical skills to deliver holistic care to patients living in their own home or care home.
• Collaborate closely with GPs and work independently to deliver safe, effective care to frail and housebound individuals, including those residing in care homes.
• Support all members of the Ageing Well team, providing guidance when necessary, conducting supervision and appraisals as required.
• Initiate and interpret tests and investigations within scope of practice.
• Administer and provide medications / treatments according to protocol and Patient Group Directions.
• Prescribe/supply medications (as appropriate) following policy, patient group directives and local pathways.
• Promote / support health & wellbeing, helping patients to remain independent and well at home.
• Facilitate patient education, self-management of disease, and behaviour modification to help reduce health inequalities.
• Conduct thorough person-centred needs assessment to develop care plans for each patient in a timely manner.
• Maintain and regularly update a comprehensive register of frail patients, utilising clinical frailty scoring tools to assess and monitor levels of frailty.
• Initiate the process of diagnosis with patients suspected to have a chronic disease e.g., diabetes, COPD, asthma, IHD referring to other clinical staff as appropriate.
• Proactively manage long term conditions alongside practice teams.
• Accurately update patient records on EMIS systems. All documentation must be timely, relevant, and clearly reflect the care provided.
• Directly admit patients to secondary care hospital in acute medical need.
• Promote clear communication with the health care team and support medication management.
• Communicate effectively with other healthcare professionals and make appropriate referrals to ensure coordinated, multidisciplinary care.
• Build and communicate therapeutic working relationships with a wide array of statutory and voluntary organisations for the benefit of patient care and facilitates good working relationships.
• Organise and chair multidisciplinary team (MDT) meetings, fostering effective working relationships with health, social care, and third-sector partners to ensure a seamless, integrated response for patients with complex needs or long-term conditions.
• Work flexibly across various healthcare settings, including surgeries, home visits, and community.
• Actively participate in clinical, PCN and practice meetings.
• Participate in team meetings, audits, and data collection for improving patient care.
• Support Social Prescribers / Care Coordinators in delivering high-quality care to frail and housebound patients.
• Provide expert clinical advice and support to patients, carers, and colleagues, maintaining high standards of professional practice and clinical excellence.
• Operate in line with clinical protocols and guidelines, ensuring professional, compassionate support for patients, families, and carers - using resources responsibly and efficiently.
• Contribute to service development through population health management tools by creating and implementing innovative models, methods, and practices to enhance primary care services for the frail population.
• Ensure compliance with practice CQC requirements and maintain accurate documentation.
• Work within all relevant PCN practice policies and procedural guidelines e.g., infection control, chaperoning, risk management.
• Contribute to PCN practice targets both local and national
• Develop own knowledge and practice to meet objectives/changes in service, through attendance on study days, self-directed learning, and reflection on practice.
• Participate in our appraisal system, matching organisational aims with individual objectives.
• Undertake all mandatory training required for the role.
• Maintain the highest standards of conduct and integrity

Duties will vary from time to time under the direction of the post holders manager, the network manager and the network clinical directors, dependent on current and evolving workload and staffing levels.

Knowledge and Skills

Essential

• Understanding of Personalised Care
• Understanding of the wider determinants of health
• Knowledge of how the NHS works, including primary care and PCNs
• Ability to recognise/work within limits of competence, seeking advice if needed
• Understanding of the needs of older people / adults with disabilities / long term conditions particularly in relation to promoting their independence
• Basic knowledge of long-term conditions and associated complexities: medical, physical, emotional and social
• Clear, polite telephone manner
• Good interpersonal skills
• Ability to record accurate clinical notes
• Proficient in MS Office and web-based services

Desirable

• EMIS Web skills

Personal Qualities

Essential

• Teamwork: Work effectively and professionally within the Ageing Well Team through willingness to proactively support and assist peers and colleagues.
• Autonomous: Ability to work independently by making informed decisions based on professional knowledge and clinical judgement
• Ability to actively listen, empathise with people and provide personalised support in a non-judgemental way.
• Ability to provide a culturally sensitive service supporting people from all backgrounds and communities, respecting lifestyles and diversity
• Solution Focussed: Ability to react to and face challenges or setbacks in a positive manner with a commitment to continuous improvement
• Commitment to reducing health inequalities and proactively working to reach people from diverse communities
• Ability to support people in a way that inspires trust and confidence, motivating others to reach their potential
• Ability to communicate effectively, both verbally and in writing, with people, their families, carers, partner agencies and stakeholders
• Ability to provide motivational coaching to support peoples behaviour change
• Ability to identify risk and assess / manage risk when working with individuals
• Strong awareness and understanding of when necessary to refer people to other
• health professionals, when the need is beyond the scope of the Ageing Well Nurse Practitioner Role.
• Ability to maintain effective working relationships and promote collaboration
• Personal accountability, emotional resilience, ability to work well under pressure
• Ability to organise, plan and prioritise on own initiative, including when under pressure and meeting deadlines
• Ability to work flexibly and enthusiastically within a team or on own initiative
• Knowledge of and ability to work to policies & procedures, e.g. confidentiality, safeguarding, lone working, information governance, and health and safety
• Demonstrable commitment to professional and personal development

Other Requirements

Essential

• Meets an enhanced Disclosure and Barring Service (DBS) check
• Access to own transport and ability to travel across the locality on a regular basis, including to visit people in their own home

Experience

Essential

• Two years recent primary or community nursing experience
• Knowledge of national standards that inform practice (NSF, NICE Guidelines)
• Experience of working in health, social care and other support roles in direct contact with people, families or carers (in a paid or voluntary capacity)
• Experience of working within multi - professional team environments
• Experience of supporting people, their families and carers in a related role
• Experience of working with elderly or vulnerable people, complying with best practice and relevant legislation

Desirable

• Experience or training in personalised care and support planning
• Experience of data collection and using tools to measure the impact of services
• An appreciation of the new NHS landscape including the relationships between individual practices, PCNs and the commissioners

Qualifications

Essential

• Current UK NMC registration and maintains revalidation
• Relevant nursing or health degree
• Independent Prescriber
• History Taking and Physical Assessment
• Experienced and up to date in blood pressure, temperature, pulse, testing blood sugars, O2 sats, tissue/skin health, diabetic foot checks
• Up to date vaccinations and immunisations training for Covid/Influenza
• Evidence of continual professional development
• Full UK Driving Licence

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.

Certificate of Sponsorship

Applications from job seekers who require current Skilled worker sponsorship to work in the UK are welcome and will be considered alongside all other applications. For further information visit the UK Visas and Immigration website (Opens in a new tab).

From 6 April 2017, skilled worker applicants, applying for entry clearance into the UK, have had to present a criminal record certificate from each country they have resided continuously or cumulatively for 12 months or more in the past 10 years. Adult dependants (over 18 years old) are also subject to this requirement. Guidance can be found here Criminal records checks for overseas applicants (Opens in a new tab).

UK Registration

Applicants must have current UK professional registration. For further information please see NHS Careers website (opens in a new window).