Job summary
We are seeking a motivated individual with a solution focused approach to
work as a Nurse as part of the Community Frailty Hub. This key role is vital in
providing comprehensive care coordination to patients living with Frailty.
Working as part of the Frailty Hub you will support this
multidisciplinary team in the prevention of unnecessary hospital admission. You
will also be case managing patients with frailty and long-term conditions to
support them to remain independent, living well in their own homes
In this busy challenging role, you will be able to work on your own
initiative, be comfortable in making decisions within the scope of your
practice whilst demonstrating an understanding of community services and using
the guidance and support of the multidisciplinary team.
Nimbuscare are committed to supporting the professional development of
our employees and fostering growth opportunities to help build a long and
rewarding career with us.
You will require use of your own car and a
driving license.
This includes evenings, weekends and Bank Holidays on
a rota basis.
Main duties of the job
Using
a Comprehensive Geriatric Assessment you will plan, implement and evaluate care
for our patients in the community.
To
act as Care Coordinator for a cohort of patients, to meet patients' needs and
preferences in the delivery of high-quality, high-value health care. Ensuring that the patient's needs and preferences are known and communicated
at the right time to the right people, and that this information is used to guide
the delivery of safe, appropriate, and effective care.
Coordinate
continuity of patient care with external organisations, including hospital
admission and discharge and referrals from the primary care provider to a
specialty care provider.
Providing
advice and guidance junior staff.
Working
across various healthcare settings, including surgeries, home visits, and
community.
Offering
on-call telephone support on a rota basis.
Mentoring
and training junior and healthcare support staff.
Facilitating
patient education, self-management of disease, and behaviour modification.
Ensuring
continuity of care, particularly during transitions like hospital admission and
discharge.
Managing
complex patients in their homes, collaborating with multidisciplinary teams.
Promoting
clear communication with the health care team and supporting medication
management.
Participating
in team meetings, audits, and data collection for improving patient care.
Ensuring
compliance with CQC requirements and maintaining accurate documentation.
About us
Nimbuscare is a not-for-profit Organisation that aims to be a collaborative and agile provider that cares for its people and patients. Nimbuscare is based in York and is owned by all the practices in the city, however we deliver services over a wider footprint.
We deliver Urgent Care services in collaboration with the hospital and GP practices in York, Scarborough, Whitby, Malton and Selby. We also provide community-based frailty care, which focuses on treating people in the community where we can. We also aim to shift services into the community where possible, for example our community diagnostic centres run in partnership with the Acute Trust.
We are committed to contributing towards a better NHS based on equity, fairness, innovation, collaboration and quality.
We are part of the system, and we are here to stay.
Nimbuscare is committed to improving the diversity of its workforce to better reflect the communities we serve. We welcome applications from everyone and work to promote an inclusive supportive culture that values and celebrates our differences.
As a Disability Confident Committed employer disabled applicants who meet the essential criteria for this job are guaranteed an interview.
Please note Nimbuscare is unable to provide any advice about visas.
There is no sponsorship available for this role.
Job description
Job responsibilities
MAIN
DUTIES OF THE ROLE INCLUDE
Using
a Comprehensive Geriatric Assessment you will plan, implement and evaluate care
for our patients in the community.
To
act as Care Coordinator for a cohort of patients; to meet patients' needs and
preferences in the delivery of high-quality, high-value health care. Ensuring
throughout that the patient's needs and preferences are known and communicated
at the right time to the right people, and that this information is used to guide
the delivery of safe, appropriate, and effective care.
Coordinate
continuity of patient care with external organisations, including hospital
admission and discharge and referrals from the primary care provider to a
specialty care provider.
Providing
advice and guidance junior staff.
Working
across various healthcare settings, including surgeries, home visits, and
community.
Offering
on-call telephone support on a rota basis.
Mentoring
and training junior and healthcare support staff.
Facilitating
patient education, self-management of disease, and behaviour modification.
Ensuring
continuity of care, particularly during transitions like hospital admission and
discharge.
Managing
complex patients in their homes, collaborating with multidisciplinary teams.
Promoting
clear communication with the health care team and supporting medication
management.
Participating
in team meetings, audits, and data collection for improving patient care.
Ensuring
compliance with CQC requirements and maintaining accurate documentation.
Managing caseloads autonomously, meeting
targets, and contributing to business goals
Job description
Job responsibilities
MAIN
DUTIES OF THE ROLE INCLUDE
Using
a Comprehensive Geriatric Assessment you will plan, implement and evaluate care
for our patients in the community.
To
act as Care Coordinator for a cohort of patients; to meet patients' needs and
preferences in the delivery of high-quality, high-value health care. Ensuring
throughout that the patient's needs and preferences are known and communicated
at the right time to the right people, and that this information is used to guide
the delivery of safe, appropriate, and effective care.
Coordinate
continuity of patient care with external organisations, including hospital
admission and discharge and referrals from the primary care provider to a
specialty care provider.
Providing
advice and guidance junior staff.
Working
across various healthcare settings, including surgeries, home visits, and
community.
Offering
on-call telephone support on a rota basis.
Mentoring
and training junior and healthcare support staff.
Facilitating
patient education, self-management of disease, and behaviour modification.
Ensuring
continuity of care, particularly during transitions like hospital admission and
discharge.
Managing
complex patients in their homes, collaborating with multidisciplinary teams.
Promoting
clear communication with the health care team and supporting medication
management.
Participating
in team meetings, audits, and data collection for improving patient care.
Ensuring
compliance with CQC requirements and maintaining accurate documentation.
Managing caseloads autonomously, meeting
targets, and contributing to business goals
Person Specification
Physical skills
Essential
- Use of own car and driving licence
Capabilities and Attributes
Essential
- Team Work: Work effectively and professionally within the community frailty hub through willingness to proactively support and assist their peers and colleagues.
- Autonomous: Ability to work independently by making informed decisions based on professional knowledge and clinical judgement.
- Time & Workload Management: The ability to quickly react to and manage changing, unpredictable and fluctuating workloads using a variety of methods of communication.
- The ability to recognise when a problem / issue should be escalated or referred for specialist investigation because it falls outside of the scope of the role and your professional knowledge.
- Solution Focussed: Ability to react to and face challenges or setbacks in a positive manner with a commitment to continuous improvement of their own skills and behaviours and also of the service
- Customer Service: Ability to remain focussed on providing and continuously improving an excellent internal customer service to the surgery team and clinical team(s)
- Deadline / Target Driven: Ability to work efficiently to strict deadlines and to be driven by the setting and achieving of individual and team targets
- Confidentiality: Ability to exercise and adhere to the Practice confidentiality policies
- Work Prioritisation: Ability to organise, prioritise and manage your own work demands by assessing levels of urgency and importance
Qualifications
Essential
Skills and knowledge
Essential
- Communication Skills
- Able to calmly, professionally and efficiently identify patients / internal customer needs
- Able to professionally and efficiently deliver patients / internal customer needs with a warm reassuring demeanour
- Able to skilfully signpost / refer the patient to the most appropriate person or alternative solution to their needs
Desirable
- IT Literate
- competent in the use of Microsoft Applications and a proven ability to learn how to navigate and interrogate systems, input data with an attention to detail and follow processes and procedures
Person Specification
Physical skills
Essential
- Use of own car and driving licence
Capabilities and Attributes
Essential
- Team Work: Work effectively and professionally within the community frailty hub through willingness to proactively support and assist their peers and colleagues.
- Autonomous: Ability to work independently by making informed decisions based on professional knowledge and clinical judgement.
- Time & Workload Management: The ability to quickly react to and manage changing, unpredictable and fluctuating workloads using a variety of methods of communication.
- The ability to recognise when a problem / issue should be escalated or referred for specialist investigation because it falls outside of the scope of the role and your professional knowledge.
- Solution Focussed: Ability to react to and face challenges or setbacks in a positive manner with a commitment to continuous improvement of their own skills and behaviours and also of the service
- Customer Service: Ability to remain focussed on providing and continuously improving an excellent internal customer service to the surgery team and clinical team(s)
- Deadline / Target Driven: Ability to work efficiently to strict deadlines and to be driven by the setting and achieving of individual and team targets
- Confidentiality: Ability to exercise and adhere to the Practice confidentiality policies
- Work Prioritisation: Ability to organise, prioritise and manage your own work demands by assessing levels of urgency and importance
Qualifications
Essential
Skills and knowledge
Essential
- Communication Skills
- Able to calmly, professionally and efficiently identify patients / internal customer needs
- Able to professionally and efficiently deliver patients / internal customer needs with a warm reassuring demeanour
- Able to skilfully signpost / refer the patient to the most appropriate person or alternative solution to their needs
Desirable
- IT Literate
- competent in the use of Microsoft Applications and a proven ability to learn how to navigate and interrogate systems, input data with an attention to detail and follow processes and procedures
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).
