About this role
Job summary
Belper PCN are seeking a Long Term Conditions Registered Nurse to provide proactive, personalised and evidence-based nursing care for adults with long-term conditions who are housebound, temporarily housebound, frail or living with complex needs. Working alongside GPs, advanced practitioners, and the wider health and care team, the postholder will assess, plan, deliver, and review care in patients usual place of residence, supporting prevention, earlier intervention, independence, and safe alternatives to hospital attendance or admission.
The role will help Belper PCN deliver the NHS 10 Year Health Plans three shifts: from hospital to community, from analogue to digital and from sickness to prevention. It will contribute to an integrated neighbourhood model in which multidisciplinary services are organised around local population need and care is delivered closer to home.
This role is a full time (37.5hrs) or can be 30hrs.
Main duties of the job
Manage an agreed caseload and waiting list of adults with single or multiple long-term conditions, prioritising those at risk of deterioration, avoidable hospital admission or health inequality.
Undertake comprehensive, holistic assessments in patients homes and care homes, considering physical and mental health, frailty, function, cognition, medicines, nutrition, falls risk, social circumstances, carer needs and safeguarding.
Complete structured long-term condition reviews within competence, including diabetes, cardiovascular disease, hypertension, respiratory disease and frailty, in line with NICE guidance and local pathways.
Work collaboratively with patients, carers and professionals to develop, implement and review personalised care and support plans, including agreed goals, self-management support, escalation arrangements and advance care planning where appropriate. Recognise deterioration and red flags, provide immediate care within scope of practice and escalate promptly to the GP, emergency services or relevant urgent care service.
Undertake and interpret clinical observations and appropriate point-of-care or diagnostic tests. Support medicines optimisation, immunisation, health promotion, prevention and self-management, where trained and authorised.
Make timely referrals, coordinate care across health, social care and voluntary services, and ensure patients and carers understand the plan, who to contact and when to seek further help.
About us
Belper PCN consists of a collaboration of 4 local GP practices working both together and with the broader health, social care, housing and voluntary organisations to improve the health and wellbeing of our local people within our neighbourhood. Our team cover urgent, planned, and anticipatory care for our patients, working with a complete integration of local services.
Belper PCN has adopted new initiatives to recruit varied skills into the PCN team. With the aim of offering community and clinical services to patients giving a more holistic approach to health care and the opportunity to access a wider selection of health professionals.
Job description Job responsibilities
Primary Responsibilities
Manage an agreed waiting list of adults with single or multiple long-term conditions, prioritising people at risk of deterioration, avoidable admission or health inequality.
Undertake comprehensive holistic assessments in patients homes and care homes, including physical health, mental wellbeing, frailty, function, cognition, medicines, nutrition, falls risk, social circumstances, carer needs and safeguarding.
Complete structured long-term condition reviews within competence, including conditions such as diabetes, cardiovascular disease, hypertension, respiratory disease and frailty, using current NICE guidance and local pathways.
Develop, implement and evaluate personalised care and support plans with patients, carers and relevant professionals, including agreed goals, self-management support, escalation arrangements and advance care planning where appropriate.
Identify early deterioration or red flags, initiate immediate care within scope of practice and escalate promptly to the responsible GP, emergency services, urgent community response or other appropriate service.
Undertake and interpret relevant clinical observations and point-of-care or diagnostic tests within competence and service protocols.
Support medicines optimisation through reconciliation, adherence review, side-effect monitoring and timely referral to a GP, clinical pharmacist or independent prescriber.
Provide immunisation, health promotion, prevention and supported self-management interventions where trained, authorised and clinically appropriate.
Make timely referrals and coordinate care across primary care, community nursing, specialist teams, pharmacy, therapy, mental health, adult social care, care homes, voluntary services, urgent community response and virtual wards.
Ensure that the patient and carer understand the care plan, who to contact and when to seek further help.
Multidisciplinary and Neighbourhood Working
Work as an integral member of the Belper PCN Home Visiting Service, collaborating with GPs, advanced clinical practitioners, nurses, nursing associates, pharmacists, care coordinators, social prescribers and other professionals.
Participate in clinical huddles, multidisciplinary meetings, care home discussions and case reviews, contributing nursing expertise and coordinated plans.
Liaise with the patients registered practice and named clinician to maintain continuity, clear accountability and timely follow-up.
Promote a no wrong door approach by helping patients and professionals navigate the most appropriate local support.
Build effective relationships with neighbourhood partners and contribute to service integration, pathway development and joint learning.
Population Health, Prevention and Digital Practice
Use PCN data, clinical registers and risk-stratification processes to help identify people who would benefit from proactive intervention, in accordance with information governance requirements.
Address modifiable risk factors, support vaccination and screening uptake, encourage rehabilitation and self-management, and signpost to local community resources.
Recognise barriers associated with deprivation, rurality, disability, cognition, language, caring responsibilities or digital exclusion; make reasonable adjustments and advocate for equitable access.
Use approved digital systems, remote monitoring and communication tools to improve continuity and efficiency while retaining face-to-face care where clinically required or preferred.
Record accurate, contemporaneous and appropriately coded information in the shared electronic patient record and support agreed outcome reporting.
Clinical Governance and Professional Practice
Practise within the Nursing and Midwifery Council Code, professional competence, indemnity arrangements, legislation, NICE guidance and Belper PCN policies.
Maintain professional registration, mandatory training and an evidence-based portfolio; participate in appraisal, clinical supervision and continuing professional development.
Obtain valid consent, assess capacity where relevant and uphold confidentiality, dignity, equality and patient choice.
Follow safeguarding, infection prevention and control, medicines management, lone-working, chaperone, incident reporting and information governance procedures.
Recognise the limits of competence, seek advice and escalate clinical uncertainty or risk to the designated senior clinician.
Contribute to audit, quality improvement, patient-safety reviews, complaints learning, patient experience and service evaluation.
Use equipment safely, maintain stock and report faults, risks or incidents promptly.
Communication, Education and Leadership
Communicate complex or sensitive information clearly and compassionately, adapting to individual communication needs and using interpreters or accessible formats when required.
Provide education and coaching to patients, carers, care-home staff and colleagues on long-term condition management, prevention and recognition of deterioration.
Support induction, peer learning and development of less experienced staff or students where appropriate.
Act as a positive role model for person-centred, integrated and improvement-focused practice.
Manage time and workload effectively, balancing planned proactive care with changing clinical priorities.
Working Conditions and Role Requirements
Regular travel across the Belper PCN area and work in patients homes, care homes and other community settings.
Ability to work independently while maintaining reliable communication and access to clinical support.
Exposure to unpredictable environments, distressing circumstances, infection risks and manual-handling considerations; all risks must be managed through policy and dynamic risk assessment.
Flexibility to work within the service operating model, which may include extended hours subject to contract.
Able to meet the travel requirements of the role; reasonable adjustments will be considered.
Appointment is subject to satisfactory employment checks, occupational health clearance and the appropriate Enhanced DBS check.
Key Working Relationships
Patients, families and unpaid carers; Belper PCN practices; GPs and the Home Visiting Service team; community nursing and specialist long-term condition teams; urgent community response and virtual wards; pharmacists and pharmacy technicians; therapists; mental health services; adult social care; care homes; voluntary and community organisations; ambulance, NHS 111, out-of-hours and secondary care services.
Person Specification
Qualifications Essential
Registered Nurse with current NMC registration; evidence of relevant continuing professional development; prepared to complete all required statutory and mandatory training.
Desirable
Degree-level study or equivalent experience; recognised long-term condition, practice nursing, community nursing, frailty, case management or advanced assessment qualification; independent/supplementary prescribing qualification
Experience Essential
Post-registration experience managing adults with long-term conditions; experience of holistic assessment, care planning and multidisciplinary working; experience supporting people with complex needs. Knowledge of evidence-based long-term condition management, prevention, personalised care and recognition of deterioration; understanding of consent, capacity, safeguarding, infection control, medicines safety, confidentiality and information governance. Able to undertake person-centred assessment, clinical observations, risk assessment, care planning, review and escalation within competence; accurate clinical documentation and use of electronic patient records.
Desirable
Primary care, community, home-visiting or care-home experience; management of multimorbidity, frailty or palliative needs; audit, quality improvement or service development experience. Knowledge of local Derbyshire pathways, urgent community response, virtual wards, enhanced health in care homes, population health management and health inequalities. Competence in relevant diagnostics, point-of-care testing, spirometry, foot assessment, injectable therapies, vaccination or remote monitoring according to service need and local authorisation.
Knowledge and Skills Essential
Clear written and verbal communication; able to explain complex information, involve patients and carers, manage difficult conversations and work constructively across organisational boundaries. Able to work independently, manage a community caseload, prioritise changing needs, recognise limits and seek timely clinical support. Competent with clinical IT, secure communication and standard office systems; able to use data and feedback to improve care. Demonstrates compassion, respect, inclusion, accountability, collaboration and commitment to high-quality, safe care; supports patient choice and tackles health inequalities. Able to travel between community locations; suitable for lone working; flexible and resilient; satisfactory occupational health, right-to-work and Enhanced DBS checks. Access to suitable transport for business use, subject to reasonable adjustments
Desirable
Experience delivering education, coaching, group consultations or supporting learners. Experience coordinating complex care or leading multidisciplinary case management Experience with SystmOne, population health tools, remote monitoring or clinical searches and reporting. Evidence of innovation, co-production or neighbourhood partnership working
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 Belper PCN
Address c/o Riversdale Surgery
Belper
Derbyshire
DE56 1AY
United Kingdom