About this role
Job summary
Farnham Integrated Care Services are looking for a housebound nurse to develop, review and enable effective care support for frail and housebound patients registered with our Farnham PCN Practices.
We are looking for 1 day a week (7.5 hours) which can be worked over 2 days if desired. This is to meet the remaining QOF need for 2026/2027. Hours and days can be flexible. This is a fixed term contract until end of March 2027 with a view to extension. Start date is as soon as possible.
Enhanced access hours may also be available.
Main duties of the job
This role will provide proactive reviews for registered housebound patients in alignment with the Quality and Outcomes Framework (QOF) targets.
This includes proactive, high-quality care management to meet both individual patient needs and PCN-wide QOF indicators.
About us
About Farnham PCN
Farnham Primary Care Network brings together GP practices and healthcare professionals to provide high-quality, patient-centred care to over 50,000 patients across the Farnham area.
We are committed to innovation, collaboration and continuous improvement, creating an environment where staff feel supported, valued and empowered to develop their careers.
Job description Job responsibilities
Core Responsibilities:
1. Patient Assessment and Care Planning
To assess, devise, and evaluate care plans for housebound patients, ensuring that their unique health needs are met in alignment with PCN and QOF care goals.
Engage with patients, families, and caregivers to promote a patient-centred approach and ensure care aligns with both patient preferences and QOF targets.
Identify patients suitable for pro-active care via the Frailty and integrated care team MDTs and remote monitoring programme. Referring as appropriate.
2. Clinical Responsibilities
Conduct long-term condition reviews, including diabetes, cancer, learning disabilities, dementia, mental health, and blood pressure management, to support QOF performance and outcomes. Working in collaboration with practices/clinicians.
Deliver specialist care in line with your scope of practice.
Use prescriptive authority (where qualified) to enhance medication management, especially in managing long-term conditions, with attention to QOF outcomes.
Provide patient and family education on managing health conditions, preventive care strategies, and self-management aligned with QOF indicators.
3. Leadership and Development
Act as a clinical role model, delivering evidence-based care and contributing to the professional development of team members.
Mentor supporting roles to achieve relevant patient outcomes.
Oversee planning and co-ordination to support effective service delivery.
4. Clinical Governance, Audit, and Research
Participate in clinical audits and research projects, implementing improvements based on findings to enhance patient care protocols.
Contribute to the development and revision of PCN guidelines, protocols, and procedures, ensuring adherence to national and local standards, including QOF requirements.
Actively engage in PCN quality improvement initiatives aimed at enhancing patient identification, assessment, and long-term support aligned with QOF.
5. Strategic and Collaborative Work
Work proactively with PMs and directors to develop integrated care pathways, contributing to a holistic model of care.
Advise on policy development and contribute to the PCNs strategic work streams.
Person Specification
Qualifications Essential
Qualified Registered Nurse with a degree in nursing or a Registered Nurse Degree Apprenticeship (RNDA). Registered with the Nursing & Midwifery Council (NMC). Level 7 or above post-graduate qualification in a relevant area, such as frailty, wound care, diabetes, respiratory/CVD, or public health management.
Desirable
Prescribing qualification is preferred, ideally Independent/Supplementary Prescriber status.
Experience Essential
Demonstrated experience in enhanced practice and familiarity with Primary Care and General Practice Nursing Career and Core Capabilities. Interest in frailty and experience in caring for elderly, housebound, or vulnerable patients. Strong communication, problem-solving, and organisational skills. Ability to work independently and within an MDT, providing leadership and mentoring as required.
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 Farnham Integrated Care Services Limited
Address Farnham Centre for Health
Hale Road
Farnham
Surrey
GU9 9QS
United Kingdom