About this role
Job summary
Morley and District Primary Care Network have an exciting opportunity for a registered Nurse to join the Proactive Care Team. We would particularly welcome a Nurse who has special interest in Frailty and Long term condition management.
This is a new role that will help support our NeighbourhoodHealth care model in Morley, along side our contractual obligations for proactive care in the community.
The suitable candidate should have a passion for making a difference in primary care and enjoy working as part of a multi-disciplinary team across clinical and non clinical services. The post holder will be part of our integrated Proactive care team, working along side Specialised ANP's, Nurses, Pharmacist, care coordinators and Health care support as well as local care partnerships.
Main duties of the job
No two days will be the same in this role, you will be active in the community and supporting patients in their home and in community venues along side our fantastic team to enable patients to live well and proactively manage their health.
The post holder will focus on proactive frailty management and the provision of preventative health care to the PCN population. You will be completing Comprehensive Geriatric Assessments, and supporting the Frailty Team in anticipatory care planning, prevention of avoidable hospital admissions, and delivery of person-centred care for patients with moderate to severe frailty, helping them remain independent and avoid unnecessary hospital admissions 999 calls or High GP attendance.
As an autonomous practitioner you will work proactively within your scope of practice, undertaking advanced clinical assessments of diagnosis and treatments. You will be responsible for the care delivered, demonstrating critical thinking and clinical decision-making in the management of your patients. You will work collaboratively within the general practice team to meet the needs of patients, supporting the delivery in accordance with policy and procedures.
About us
Morley and District PCN is a collaborative network, supporting 6 practice's in our locality with approximately 65,000 patients. We are rapidly developing our multi-disciplinary workforce, embedding our roles, developing our team that makes a real difference to our patients and our practices.
Job description Job responsibilities
Clinical practice. frailty and proactive care.
Assess and evaluate treatment programmes that promote health and well-beingUndertake Comprehensive Geriatric Assessments (CGA)Support anticipatory care planning and advance care planning discussions Assess, plan, and evaluate individual treatment plans for patients with a known long-term condition Proactively identify, diagnose and manage treatment plans for patients at risk of developing a long-term condition as appropriate Work with other health care professionals to diagnose, monitor, manage and treat long-term conditions, including holistic and non-drug-based treatment methods using a management plan, and in line with national and local policies and practice needs Prioritise health problems and intervene before appropriately to assist the patient in complex, urgent or emergency situations Support patients to adopt health promotion strategies that promote patients to live healthily, and apply principles of self-care Recognise, assess and refer patients presenting with mental health needs in accordance with the NSF for Mental Health Implement and participate in vaccination and immunisation programmes for adults.Support delivery of PCN proactive care and personalised care programmesWork collaboratively with community services to reduce avoidable admissions and improve patient outcomesCommunication
Demonstrate sensitive communication styles to ensure patients are fully informed and consent to treatment Communicate with and support patients receiving bad news Communicate effectively with patients and carers, recognising the need for alternative methods of communication to overcome different levels of understanding, cultural background and preferred ways of communicating Anticipate barriers to communication and take action to improve communication Estimate and maintain effective communication with individuals and groups within the practice environment and with external stakeholders Act as an advocate when representing patients and colleagues Delivering a quality service
Recognise and work within own competence and professional code of conduct as regulated by the NMC Produce accurate, contemporaneous and complete records of patient consultation, consistent with legislation, policies and procedures Prioritise, organise and manage own workload in a manner that maintains and promotes quality Deliver care according to NSF, NICE guidelines and evidence-based care Assess effectiveness of care delivery through self and peer review, benchmarking and formal evaluation Participate in the maintenance of quality governance systems and processes across the practices Utilise the audit cycle as a means of evaluating the quality of the work of self and the team, implementing improvements where required Collaborate on improving the quality of health care in partnership with other clinical teams, responding to local and national policies and initiatives as appropriate Evaluate the patients response to health care provision and the effectiveness of care Support and participate in shared learning across the practice and wider organisation Assess the impact of policy implementation on care delivery Understand and apply legal policy that supports the identification of vulnerable and abused children and adults, being aware of statutory child/vulnerable adult health procedure and local guidance Work within policies regarding family violence, vulnerable adults, substance abuse and addictive behaviour, and refer as appropriate Leadership personal and people development
Take responsibility for own development learning and performance including participating in clinical supervision and acting as a positive role model Support the development of others in order to maximise potential Actively promote the workplace as a learning environment, encouraging everyone to learn from each other and from external good practice Participate in planning and implementing changes within the area of care and responsibility Contribute and participate in the development of local guidelines, protocols and standards Participate in the planning and engagement of practice-based commissioning or similar initiatives Ensure awareness of sources of support and guidance (eg PALS), and provide information in an acceptable format to all patients, recognising any difficulties and referring where appropriate Team working
Understand own role and scope, and identify how this may develop over time Work as an effective and responsible team member, supporting others and exploring the mechanisms to develop new ways of working Delegate clearly and appropriately, adopting the principles of safe practice and assessing competence Ensure clear referral mechanisms are in place to meet patient need Prioritise own workload and ensure effective time-management strategies are embedded within the culture of the team Work effectively with others to clearly define values, direction and policies impacting upon care delivery Participate in team activities that create opportunities to improve patient care Participate in and support local projects as agreed with the practice management team Management of risk
Manage and assess risk within the areas of responsibility, ensuring adequate measures are in place to protect staff and patients Monitor work areas and practices to ensure they are safe and free from hazards and conform to health, safety and security legislation, policies, procedures and guidelines Ensure safe storage, rotation and disposal of vaccines Support members of the nursing team to undertake mandatory and statutory training requirements Apply infection-control measures within the practice according to local and national guidelines Apply policies that reduce environmental health risks, are culturally sensitive and increase access to health care for all Participate in the local implementation strategies that are aligned to the values and culture of general practice Utilising information
Use technology as an aid to management in planning, implementation and monitoring, presenting and communicating information Review and process data using accurate Read codes to ensure easy and accurate retrieval for monitoring and audit processes Manage information searches using the internet and local library databases, for example, the retrieval of relevant information for patients on their condition Understand the responsibility of self and others regarding the Freedom of Information Act Learning and development
Disseminate learning and information gained to other team members in order to share good practice and inform others about current and future developments Assess own learning needs and undertake learning as appropriate Make effective use of learning opportunities within and outside the workplace, evaluating their effectiveness and feeding back relevant information Provide an educational role to patients, carers, families and colleagues in an environment that facilitates learning Equality and diversity
Identify patterns of discrimination, take action to overcome this, and promote diversity and quality of opportunity Enable others to promote equality and diversity in a non-discriminatory culture Support people who need assistance in exercising their rights Monitor and evaluate adherence to local chaperoning policies Act as a role model in the observance of equality and diversity good practice Accept the rights of individuals to choose their care providers, participate in care and refuse care Assist patients from marginalised groups to access quality care
Person Specification
Other Essential
Self-directed practitioner Highly motivated Flexibility Enthusiasm Team player Ability to work across boundaries
Experience Essential
Minimum 1 years post registration experience At least 2 years recent primary and community nursing experience Experience of nurse-led management of long-term conditions Experience of implementing protocols and clinical guidelines Experience of quality initiatives such as clinical benchmarking Audit experience Experience managing people with frailty and multiple long-term conditions Experience of autonomous clinical decision making Experience undertaking home visits Experience of multidisciplinary team working Experience of clinical assessment and diagnosis of complex patients.
Desirable
Experience of working in a GP practice Experience of working in Primary Care Experience of Comprehensive Geriatric Assessment. Experience of service development and quality improvement
Knowledge Essential
Knowledge of management of patients with long-term conditions Knowledge of accountability of own role and other roles in a nurse-led service Knowledge of health promotion strategies Knowledge of local and national health policy Wider health economy awareness Knowledge of clinical governance issues in primary care Knowledge of patient group directions and associated policy
Desirable
Knowledge of public health issues Ability to identify determinants on health in the local area Knowledge of public health issues in the area
Qualifications Essential
Registered Nurse with current NMC registration Community nursing specialist qualification or equivalent Advanced clinical assessment and diagnostic skills Knowledge of frailty management Understanding of Comprehensive Geriatric Assessment Knowledge of personalised care and anticipatory care planning Understanding of safeguarding adults Excellent communication and interpersonal skills Ability to work independently and manage competing priorities
Desirable
Clinical supervision training and experience Independent or supplementary nurse prescribing qualification Ability to influence and lead change
Skills Essential
Clinical leadership skills Clinical skills immunisation and vaccination Change-management skills and ability to support patients to change lifestyle Communication skills, both written and verbal Ability to communicate difficult messages to patients and families Negotiation and conflict management skills IT skills
Desirable
Worked on System 1
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).
Employer details Employer name Morley and District PCN
Address Windsor House Surgery
2 Corporation Street
Morley
Leeds
LS27 9NB
United Kingdom
Employer's website https://www.leighviewmedical.co.uk/ (Opens in a new tab)