Job summary
Are you a highly motivated and forward-thinking nurse passionate about proactive, person-centred care?
Cross Gates Primary Care Network (PCN) offers an exciting opportunity to be part of a dynamic, multidisciplinary team delivering innovative and integrated healthcare to our vibrant East Leeds community.
The Opportunity
At Cross Gates PCN, you will be joining a well-established collaboration of four practices operating across seven sites: Ashfield and The Grange Medical Centre, Colton Mill and The Grange Medical Centre, Family Doctors, and Manston Surgery serving over 32,000 patients, including those in five care homes. You will be central to our mission of preventative and personalised care, helping to reduce health inequalities and support people to live independently for longer.
We are proud to foster a culture where clinical leadership, professional growth, and collaborative working thrive. You will work alongside a rich and diverse multidisciplinary team, including clinical pharmacists, pharmacy technicians, mental health practitioners, ACPs,
Main duties of the job
Proactive Case Finding and Population Health Management Utilise population health data,clinical judgement and multidisciplinary input to identify individuals at high risk of deterioration,unplanned admission,or loss of independence.Proactively address social,clinical, and environmental factors influencing health,focusing on frailty, multimorbidity and complex needs.
Anticipatory and Personalised Care Planning Lead the development of holistic,person-centred care plans with patients,carers,and the wider neighbourhood team.Ensure plans reflect individual priorities and include shared decision-making,preventative actions,and escalation planning.
Prevention,Screening,and Health Promotion Deliver targeted screening,lifestyle advice,and health coaching that promote self-management and reduce risk of deterioration.Support outreach and public health efforts tackling inequalities and improving neighbourhood wellbeing.
Integrated Working and Care Coordination Participate in multi-agency team meetings and neighbourhood huddles to coordinate timely care across primary care,social care,community health,and the voluntary sector.Act as a clinical resource and patient advocate.
Avoiding Unnecessary Hospital Admissions Implement early intervention and crisis prevention strategies to support people remaining at home when safe.Provide clinical input and leadership in community alternatives to hospital, including enhanced case management and rapid response.
About us
We are proud of our proactive approach in adopting new models of care and adapting digital solutions that enhance patient experience and staff wellbeing including a Respiratory Pilot,Dementia Specialist Nurse Service,Lipid Optimisation,East Leeds Collaborative Health Bus and drive through vaccine clinics,Weight Management Specialist Service,General Practice Improvement Programme and a Frailty and Enhanced Care Home Service
Integrated Neighbourhood Working:Collaborate closely with community teams,Cross Gates LCP,voluntary partners including Linking Leeds,memory support workers, neighbourhood teams and Cross Gates Good Neighbours to deliver holistic care
Career Development:We invest in our nursing workforce through ongoing training,peer support,clinical supervision and leadership opportunities within areas such as frailty,long-term condition management,anticipatory care and quality improvement
Real Impact:This is your chance to make a tangible difference in peoples lives in our community especially those living with complex health needs while helping shape the future of proactive, community-based care.
Strong Nursing Support and Leadership:In addition to working alongside a wide range of health professionals,you will benefit from dedicated nursing leadership and peer support.This includes access to the clinical director,nurse associates,specialist nurses and advanced nurse practitioners,ensuring you are clinically supported and professionally empowered at every stage of your role.
Job description
Job responsibilities
Anticipatory and Person-Centred Care Planning: Working closely with the Frailty Team, you will lead and support the delivery of anticipatory care planning for individuals at risk of hospital admission, particularly those living with frailty, complex needs, or long-term conditions. Develop and monitor personalised care plans that reflect patient goals, preferences, and clinical needs.
Early Identification and Clinical Reviews: Support the early identification of patients with deteriorating health through regular case-finding and clinical reviews, using tools such as the Frailty Index, Q-Risk, and professional judgement to inform proactive interventions.
Comprehensive Holistic Assessment: Undertake thorough clinical assessments that consider physical, psychological, and social dimensions of care, supporting the delivery of safe, individualised, and effective treatment.
Supporting Self-Management and Independence: Coordinate and deliver interventions that promote self-management, resilience, and independence, enabling patients to take an active role in their health and care planning.
Community-Based Care Delivery: Conduct regular clinical reviews in clinic settings and provide home visits for housebound patients or those residing in care homes, ensuring continuity and equity of access.
Health Promotion and Prevention: Deliver education, support, and interventions related to disease prevention, lifestyle modification, and health promotion. Engage with patients and communities to raise awareness of key public health messages.
Screening and Vaccination Participation: Participate in seasonal vaccination programmes, NHS screening initiatives, and health surveillance campaigns, ensuring timely uptake and follow-up where needed.
Chronic Disease Monitoring and Support: Provide clinical care and monitoring for patients with chronic conditions including diabetes, hypertension, chronic kidney disease, respiratory illnesses, and cardiovascular disease. Tailor interventions to meet individual clinical and lifestyle needs.
Collaborative Clinical Management: Work closely with GPs, practice teams, and specialist services to optimise long-term condition management, reduce complications, and minimise hospital admissions.
Evidence-Based Practice: Utilise clinical protocols, national guidelines, and best practice frameworks to deliver safe, effective, and personalised long-term care.
Job description
Job responsibilities
Anticipatory and Person-Centred Care Planning: Working closely with the Frailty Team, you will lead and support the delivery of anticipatory care planning for individuals at risk of hospital admission, particularly those living with frailty, complex needs, or long-term conditions. Develop and monitor personalised care plans that reflect patient goals, preferences, and clinical needs.
Early Identification and Clinical Reviews: Support the early identification of patients with deteriorating health through regular case-finding and clinical reviews, using tools such as the Frailty Index, Q-Risk, and professional judgement to inform proactive interventions.
Comprehensive Holistic Assessment: Undertake thorough clinical assessments that consider physical, psychological, and social dimensions of care, supporting the delivery of safe, individualised, and effective treatment.
Supporting Self-Management and Independence: Coordinate and deliver interventions that promote self-management, resilience, and independence, enabling patients to take an active role in their health and care planning.
Community-Based Care Delivery: Conduct regular clinical reviews in clinic settings and provide home visits for housebound patients or those residing in care homes, ensuring continuity and equity of access.
Health Promotion and Prevention: Deliver education, support, and interventions related to disease prevention, lifestyle modification, and health promotion. Engage with patients and communities to raise awareness of key public health messages.
Screening and Vaccination Participation: Participate in seasonal vaccination programmes, NHS screening initiatives, and health surveillance campaigns, ensuring timely uptake and follow-up where needed.
Chronic Disease Monitoring and Support: Provide clinical care and monitoring for patients with chronic conditions including diabetes, hypertension, chronic kidney disease, respiratory illnesses, and cardiovascular disease. Tailor interventions to meet individual clinical and lifestyle needs.
Collaborative Clinical Management: Work closely with GPs, practice teams, and specialist services to optimise long-term condition management, reduce complications, and minimise hospital admissions.
Evidence-Based Practice: Utilise clinical protocols, national guidelines, and best practice frameworks to deliver safe, effective, and personalised long-term care.
Person Specification
Experience
Essential
- Experience working in primary care, community or proactive care setting
- Experience of managing patients with long-term conditions and complex needs
- Experience of anticipatory or personalised care planning
- Health Promotion
- Phlebotomy
- Basic Wound Care
- Immunisation
- Working in a multidisciplinary team
- Experience supervising students or junior staff
- Using electronic healthcare record systems
- Microsoft Office Packages (Teams, Word, Excel, Powerpoint)
- Using SystmOne or EMIS clinical system
- Experience contributing to service development, audits or QI initiatives
Desirable
- Leadership and management
- Proactive and Advanced Care Planning
- Cervical Screening
- Advanced Wound Care
- Leg Ulcer management
- Managing and investigation of incident reporting
- Spirometry and Interpretation
- Research
Qualifications
Essential
- Registered Nurse (Adult) with current NMC Registration
- Hold (or about to be awarded) a first level degree in nursing
- GCSE Maths equivalent to 5 or above (or C or above)
- GCSE English equivalent to 5 or above (or C or above)
- Certificate in phlebotomy
- Cardiovascular Disease management
- Certificate in vaccinations
- Wound Care Certificate
- All mandatory training certificates
- Relevant post-registration qualification (e.g. chronic disease management, frailty, palliative care)
- Evidence of ongoing professional development
Desirable
- Leadership Certificate
- Teaching, mentoring or practice assessor qualification
- Research Certificate
- Leg Ulcer Management Certificate
- Cervical Screening Certificate
- Spirometry Certification
- Palliative / End of Life Care Certification
- Independent/supplementary
Person Specification
Experience
Essential
- Experience working in primary care, community or proactive care setting
- Experience of managing patients with long-term conditions and complex needs
- Experience of anticipatory or personalised care planning
- Health Promotion
- Phlebotomy
- Basic Wound Care
- Immunisation
- Working in a multidisciplinary team
- Experience supervising students or junior staff
- Using electronic healthcare record systems
- Microsoft Office Packages (Teams, Word, Excel, Powerpoint)
- Using SystmOne or EMIS clinical system
- Experience contributing to service development, audits or QI initiatives
Desirable
- Leadership and management
- Proactive and Advanced Care Planning
- Cervical Screening
- Advanced Wound Care
- Leg Ulcer management
- Managing and investigation of incident reporting
- Spirometry and Interpretation
- Research
Qualifications
Essential
- Registered Nurse (Adult) with current NMC Registration
- Hold (or about to be awarded) a first level degree in nursing
- GCSE Maths equivalent to 5 or above (or C or above)
- GCSE English equivalent to 5 or above (or C or above)
- Certificate in phlebotomy
- Cardiovascular Disease management
- Certificate in vaccinations
- Wound Care Certificate
- All mandatory training certificates
- Relevant post-registration qualification (e.g. chronic disease management, frailty, palliative care)
- Evidence of ongoing professional development
Desirable
- Leadership Certificate
- Teaching, mentoring or practice assessor qualification
- Research Certificate
- Leg Ulcer Management Certificate
- Cervical Screening Certificate
- Spirometry Certification
- Palliative / End of Life Care Certification
- Independent/supplementary
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).
