THE PCN Nurse Practitioner Care Homes Team

Channel Health Alliance

This job is now closed

Job summary

This is an innovative, clinically led Care Homes Service, provided by Channel Health Alliance on behalf of the East and West Primary Care Networks (PCN). The post holder will work within an integrated Care Homes Team to proactively support practices of the East and West PCN’s allocated Care Homes providing proactive support as part of the wider MDT.

The post holder is an experienced nurse of a minimum of 3 years post registration training, who acting within their professional boundaries, will provide care for the patient from initial history taking, treatment and evaluation of their care. They will demonstrate safe, clinical decision-making and reasoning and care for patients within care homes on behalf of the PCN practices. They will work collaboratively with the multi-disciplinary care homes team and general practice team to meet the needs of patients, supporting the delivery of the Enhanced Health in Care Homes DES.

The post holder will be able perform comprehensive assessments of older people living with illness or long term conditions which affect their daily lives. This involves close inter-disciplinary working with nurses, therapists, pharmacists, dietitians, social workers and many other health and care professionals. In addition, working closely with GPs, Old Age Psychiatrists, hospital clinical specialists and frailty services to ensure that older people receive the highest possible levels of care.

Main duties of the job

· To comprehensively assess patients with complex physical, mental and social care needs using, detailed history taking and biometric monitoring and evaluation skills.

· To have an understanding of the combined impact of all of the patient’s conditions on their health and social care needs in order to improve health outcomes and quality of life.

· Develop individualised treatment and management plans using evidence based practice and proactively monitor patients and review care plans

· To maintain accurate, contemporaneous, and comprehensive records of care, using recording systems used within the care homes team.

· To work as an autonomous practitioner, managing and prioritising own caseload, through clinical judgement, according to local and national guidelines and identified need.

· To understand multiple chronic diseases, cognitive and functional impairment.

· To identify and plan preventative measures and anticipatory care needs in accordance with patient presentation and care needs

· To proactively monitor patients and review care plan whilst using an MDT approach.

About us

Channel Health Alliance, a GP company, made up of the majority of shareholders practices across South Kent Coast is seeking to recruit a nurse for Total Health Excellence Care Homes Team. This role is to work within the care home multidisciplinary team supporting general practice to deliver the Enhanced Health in Care Homes DES. This post will work clinically with the existing nurse practitioner, care coordinators and GP the smooth delivery, of a high quality and safe service to the PCN care home patients.

Date posted

19 December 2023

Pay scheme

Other

Salary

£22,300 a year

Contract

Permanent

Working pattern

Part-time, Flexible working

Reference number

B0253-22-4450

Job locations

180 Sandgate Road

Folkestone

Kent

CT20 2HN

Job description

Job responsibilities

· To work in collaboration with patients and carers, identifying self-management needs and increase their knowledge of their condition, in order that they develop skills to manage their condition effectively where this is possible

· To provide the necessary tools and equipment to carers so that they can monitor their condition, identify warning signs of complications and crisis and know when to call for support

· To provide information to patients, their carers and families so they can make informed choices about current and future care needs.

· To work in collaboration with t all health, social care and voluntary agencies to provide care for patients and their families and carers, within given resources.

· To work in partnership on the development, management and ongoing review of the care plan with the patients GP, specialists, pharmacists, social care and other services and professions as required.

· To prioritise and coordinate the multiple health care needs of the patient.

· To negotiate and agree with patient, informal carer/family and other care professionals, individual roles, and responsibilities with actions to be taken and outcomes to be achieved, referring on to other services or professions as appropriate.

· Maintain responsibility for the patient’s pathway throughout all components of the health and social care system to prevent duplication, and delays in care.

· To establish and maintain effective communication and liaison with the Primary Health Care Team and other agencies involved in caring for patients in the Community i.e. voluntary and statutory agencies, relatives and carers.

· To communicate in a professional and sensitive manner with people, their relatives and carers taking into consideration their need for dignity, privacy and independence as well as their cultural and spiritual value

· To establish and maintain productive relationships with carers and care providers through effective communication. Supporting and influencing training needs, alleviating concerns, barriers and facilitating effective communication between these services in order to enhance care homes to deliver highly quality care.

· To effectively communicate at all levels of the organisation; to a variety of health and social care professionals working in primary, community and secondary care, out of hours providers, voluntary organisations and patients and carers..

· To maintain accurate and up-to-date patient records, informing other professionals about changes in the patient’s condition where appropriate.

· To provide high quality written reports and any other written documentation as necessary.

· To act as advocate for the patient as required to ensure their individual needs, preferences and choices are delivered.

· To assist in developing systems for auditing in order to determine standards of practice and use research awareness skills to critically appraise the effectiveness of practice.

· To submit statistical and contractual monitoring returns within agreed time scales.

· To participate in the development, implementation and evaluation of protocols, guidelines, policies, integrated care pathways and tools.

· To participate in the evaluation regarding the process, outcomes and impact of the care homes team and to help develop service delivery

· To act as a change agent and innovator and lead on the development of new systems and ways of working across the whole system to meet the needs of people with complex multiple long term needs.

· To provide support to newly recruited team members.

· To provide education and training for other staff and students including pre- and post- registration nursing students

· To proactively access appropriate and relevant training opportunities that will enhance both personal and professional development.

· Work collaboratively with training providers to support carers and care home providers by signposting available training to enhance knowledge.

· To exercise leadership and judgment to ensure good clinical practices and maintain high standards of care and review these at regular interviews.

· To be actively involved with performance and clinical audits.

· The post holder will also provide clinical supervision to care coordinators

· The post holder may also line manage other staff members as the service develops

· This job description lists the main tasks but is not exhaustive and will be regularly reviewed and updated in discussion with the post holder and their Line Manager.