PCN Care Home Nurse Practitioner (Aging Well)

Job responsibilities

1. Scope and Purpose of The Role

Nurse Practitioner Role:

Deliver weekly ward round and ensure that patients are prioritised appropriately for immediate support or for next MDT.

Ensuring that MDTs are held and that assessments cover patient needs.

Ensuring that all patients have care plans and new residents have care plans within seven days, developed with the person and their carer.

Support delivery of each patients care plan.

Overview of requirements from GPs (via Care Home Co-ordinators) allocated to each care home and escalating to GP where necessary for patient treatment.

Work closely with and supervising Care home co-ordinator for care homes allocated to the PCN.

Establish protocols between care home system partners for information sharing, shared care planning, use of shared care records and clear clinical governance.

Support discharge from hospital and transfers of care between settings, including giving due attention to NICE Guideline 27.

Manage a clinical caseload, dealing with patients needs in a Nursing & Care

Home setting.

Provide advanced nursing care and case management to patients with multiple

complex long-term conditions.

Undertake nursing, medical and social care assessment to initiate interventions.

to improve quality of life in the Nursing & Care Home setting

Reduce fragmentation of care.

Provide education, training and support to the nursing & care home team (where applicable) and ensure the highest standards of care are provided for patients.

Deliver a high standard of patient care as a Nurse Practitioner in Nursing & Care Homes, using advanced autonomous clinical skills, and a broad and in-depth theoretical knowledge base.

Ensure that internal and external quality standards are met and maintained, including standards laid down by the Care Quality Commission and commissioners

Support the PCN Manager, Clinical Director in the development of clinical protocols that safeguard the wellbeing of Care Home patients and address public health, prescribing and other related NHS requirements.

Promptly review significant events, and recognise, promote and implement learning outcomes.

To act as a positive role model which promotes team working, respect, innovation and excellence.

Work with the Care Home GP Lead and Clinical Director and other key staff to develop strategic plans for the organisation, consistent with and supportive of the strategic direction of key partners.

2. Job Dimensions

To manage own clinical workload in Nursing & Care Homes responding effectively to patient need and ensuring patient choice and ease of access to services.

The development and use of referral pathways for NPs.

To mentor and support other Health Care Professionals in developing and

maintaining clinical skills including Care Home Co-ordinator.

3. Organisational Chart

4. Knowledge, Skills and Experience Required

See person specification

5. Primary Duties & Areas of Responsibility

A. CLINICAL ROLE:

The post-holder will:

Work with multi-disciplinary team within the PCN, and across the wider Health

Economy, to promote integrated and seamless pathways of care.

Make professionally autonomous decisions for which he/she is accountable

Provide a first point of contact for Nursing & Care Homes for advice regarding medical/nursing conditions of patients, making use of skills in history taking, physical examination, problem-solving and clinical decision-making.

Instigate necessary invasive and non-invasive diagnostic tests or investigations

and interpret findings/reports

Where the post holder is an independent prescriber: to prescribe safe, effective

and appropriate medication as defined by current legislative framework

Provide safe, evidence-based, cost-effective, individualised patient care

Offer a holistic service to patients and their families, developing where

appropriate an on-going plan of care/support, with an emphasis on prevention

and self-care

Promote health and well-being through the use of health promotion, health

education, screening and therapeutic communication skills

Refer patients directly to other services/agencies as appropriate

Work with nursing, medical and health care co-ordinator colleagues to ensure that

National Service Frameworks (e.g. Coronary Heart Disease/Older People/

Diabetes /Mental Health) are being delivered

Sustain & maintain high standards of patient care and service delivery

Participate in identification of community health needs and develop patient/family-centred strategies to address them.

Support for the Care Coordinator(s) with their work and any other junior nurses who may be appointed in the future.

Supervisory and Mentoring Role:

The post-holder will:

Deliver mentoring support and guidance as required.

Ensuring the EHCH DES is being delivered by the team.

Contribute to Identifying and supporting any training requirements for Care Home Co-ordinator.

C. Professional Role:

The post-holder will:

Monitor the effectiveness of their own clinical practice through the quality

assurance strategies such as the use of audit and peer review

Maintain their professional registration

Participate in continuing professional development opportunities to ensure that

up-to-date evidence-based knowledge and competence in all aspects of the role

is maintained

Develop and maintain a Personal Learning Plan

Work within the latest NMC Code of Professional Conduct

Record accurate consultation data in patients records in accordance with the

latest NMC guidance and other pertinent standards

Keep up to date with pertinent health-related policy

Work collaboratively with colleagues within and external partners.

Pro-actively promote the role of the NP internally and to key

stakeholders and agencies

Encourage and develop teamwork.

Participate in multi-disciplinary protocol and Patient Group Directions development

Participate in MDT meetings reporting progress as required. The only reason

for not attending will be annual, study or sick leave.

Participate in audits and inspections as appropriate.

6. Health and Safety/Risk Management

The post-holder will assist in promoting and maintaining their own and others health, safety and security as defined in the practice Health & Safety Policy, to include:

The post-holder must comply at all times with Health and Safety policies, in particular by following agreed safe working procedures and reporting incidents.

The post-holder will comply with the Data Protection Act (1984) and the Access

to Health Records Act (1990).

• Using personal security systems within the workplace according to practice guidelines;
• Identifying the risks involved in work activities and undertaking such activities in a way that manages those risks;
• Making effective use of training to update knowledge and skills;
• Using appropriate infection control procedures, maintaining work areas in a tidy and safe way and free from hazards;
• Reporting potential risks identified.

7. Equality and Diversity

The post-holder will support the equality, diversity and rights of patients, carers and colleagues, to include:

Acting in a way that recognises the importance of peoples rights, interpreting them in a way that is consistent with practice procedures and policies, and current legislation;

Respecting the privacy, dignity, needs and beliefs of patients, carers and colleagues;

8. Confidentiality

• In the course of seeking treatment, patients entrust us with, or allow us to gather, sensitive information in relation to their health and other matters. They do so in confidence and have the right to expect that staff will respect their privacy and act appropriately;
• In the performance of the duties outlined in this Job Description, the post-holder may have access to confidential information relating to patients and their carers, practice staff and other healthcare workers. They may also have access to information relating to the practice as a business organisation. All such information from any source is to be regarded as strictly confidential.

The post-holder must respect patient confidentiality at all times and not divulgepatient information unless sanctioned by the requirements of the role.

9. Communication and Working Relationships

The post-holder will establish and maintain effective communication pathways

using IT systems where appropriate with the following:

Clinical Director

PCN GP Lead

GPs aligned to Care Homes

Care Home Coordinator/s

Representatives from care homes

Community Nurses

Linked Mental Health Nurse

PCN Pharmacist

Social care professional

Member from Age Concern Tyneside South (ACTS)

Other health and care representatives

10. Special Working Conditions

The post-holder is required to travel independently between care homes (wereapplicable), and to attend meetings etc hosted by other agencies.

The post-holder will have contact with body fluids i.e., wound exudates; urine etc.while in clinical practice.

This Job Description provides a guide to the duties and responsibilities of the post and is not an exhaustive list. The post holder may be asked to undertake any other relevant duties appropriate to the post. The Job Description may be amended over time, in consultation with the post holder to meet the needs of the service.

Qualifications

Essential

• Registered General Nurse (Currently registered with the Nursing & Midwifery Council).
• Clinical Skills Qualification (or working towards completion of this, this may affect remuneration at point of job offer).

Desirable

• Teaching / Mentoring
• experience and /or qualification
• Independent Nurse Prescriber
• Recognised NP qualification at Masters level or equivalent

Knowledge

Essential

• Understanding and knowledge of policy developments related to the delivery of primary care services including General Practice, the GMS/PMS contract, Clinical Governance, Quality & Outcomes Framework.
• Understanding of evidence-based practice.
• Knowledge of national standards that inform practice (e.g., National Service Frameworks, NICE guidelines etc.).
• Knowledge of the Mental Capacity Act.
• Understanding of their accountability arising from the NMC Code of Professional Conduct (2004) and medico-legal aspects of the Nurse Practitioner role including Safeguarding.
• Understanding of equal opportunity and diversity issues.

Experience

Essential

• Minimum of 5 years post registration experience including 2 years in Primary and Community Care.
• Experience in management long term conditions e.g., asthma, COPD, diabetes, CHD.
• Evidence of appropriate continuing professional development activity to maintain up-to-date knowledge and on-going competence in all aspects of the NP role.
• Proven ability to evaluate the safety and effectiveness of their own clinical practice.
• Experience with advanced care planning.

Desirable

• Interpreting and implementing local and National policy agendas for health.
• Evidence of working autonomously and as part of a team.
• Experience of working with patients with complex multi-morbidity including dementia.
• Experience of hosting MDTs.
• Experience and awareness of the local Frailty agenda.
• Experience of writing comprehensive Care Plans.
• Experience of being within a lead role previously.

Skills

Essential

• Ability to assess and manage patient risk effectively and safely.
• Well-developed word processing/data collection/IT skills.
• Excellent interpersonal, verbal and written communication skills.
• Reflective practitioner.
• Time management and ability to prioritise workload.
• Able to analyse data and information, drawing out implications for the individual patient/impact on care plan.
• Able to establish and maintain effective communication pathways with key stakeholders.
• Self-motivated.
• Organisational skills.
• Enthusiastic.
• Car driver/access to car.

Desirable

• Experience of use of a medical software package.
• Proven record of effective use of networking and influencing skills.
• Ability to think strategically.
• Experience of presenting information to wider audience.
• Ability to work flexible hours when required.
• Ability to work across multiple care homes and practices.

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).