About this role
Job summary We are looking for an experienced community or practice nurse, to join our already established Home Visiting and Care Home team. The nurse will provide home visits for housebound patients and care home residents within the PCN, these visits will include completing patients annual reviews for long term conditions (such as Diabetes), frailty assessments, and advanced care plans (including DNACPR status) to support both the practices QOF (Quality and Outcomes Framework) and the PCN Proactive Care contracts.
The post holder will be required to provide visits for patients in their own home who require updated observations and general reviews and assessments. The practitioner will also need to visit patients living in care homes. The clinician will be responsible for prioritising workload and will be required to take a comprehensive history and devise a comprehensive patient focused plan. This could include liaison with the GP, secondary care and community colleagues to support coordination of patient care.As part of the proactive care service delivery, the post holder will be required to complete comprehensive frailty assessments and care plans.They can also take part in end of life care planning, and medication optimisation dependent on experience. They will work closely with a wider MDT to identify patients who require input from other services or agencies.
Main duties of the job
Uses expert knowledge and clinical skills to deliver holistic care to housebound patients and care home residents registered with Southampton West PCN
Support the ongoing management of long-term conditions for patients in the PCN
Create care plans and frailty assessments for patients using specific templates required under the proactive care contract Refers patients, as appropriate, to other members of the multidisciplinary team, secondary care and to other statutory and voluntary organisations Works within professional guidelines and codes of conduct Works within all relevant policies and procedural guidelines e.g. infection control, chaperoning, risk management Communicates information well and sensitively to patients and carers having due regard to confidentiality Contributes towards targets under the primary Care Network Enhanced service and the Quality and Outcomes Framework Undertakes and completes quality improvement projects where necessary Accurately records clinical consultations on practice clinical systems ensuring the correct use of SNOMED codes and clinical templates Understands and implements safeguarding protocols and understand how and who to refer and escalate to when required Develops meaningful positive working relationships with local frailty teams and Multi Disciplinary Team Helps to deliver vaccination programmes for our housebound populations and care home residents
About us
Southampton West Primary Care Network (PCN) consists of the 9 GP surgeries in the west of the City and covers 84,000 patients. Our mission is to work collaboratively to develop high quality services for our patients, so that we can improve health outcomes that enable people to live well, for longer, whilst developing resilient primary care.
The PCN already hosts a strong and supportive multi-disciplinary wellbeing team consisting of mental health practitioners, peer support workers, social prescribers, care coordinators, Health and Wellbeing Coaches, Pharmacists, and First Contact Physiotherapists.
Employer details Southampton West PCNShirley Health Partnership
355 Shirley Road
Southampton
Hampshire
SO15 3JD
Job description Job responsibilities
Uses expert knowledge and clinical skills to deliver holistic care to housebound patients and care home residents registered with Southampton West PC
Provide safe, evidence-based, cost effective, individualised patient care
Support the ongoing management of long-term conditions for patients in the PCN
Create care plans and frailty assessments for patients using specific templates required under the proactive care contract
Refers patients, as appropriate, to other members of the multidisciplinary team, secondary care and to other statutory and voluntary organisations
Works within professional guidelines and codes of conduct
Works within all relevant policies and procedural guidelines e.g. infection control, chaperoning, risk management
Communicates information well and sensitively to patients and carers having due regard to confidentiality
Contributes towards targets under the primary Care Network Enhanced service and the Quality and Outcomes Framework
Undertakes and completes quality improvement projects where necessary
Accurately records clinical consultations on practice clinical systems ensuring the correct use of SNOMED codes and clinical templates
Understands and implements safeguarding protocols and understand how and who to refer and escalate to when required
Develops meaningful positive working relationships with local frailty teams and Multi Disciplinary Teams
Helps to deliver vaccination programmes for our housebound populations and care home residents
Person Specification
Knowledge and Skills Essential
Communication and consultation skills Practising holistically Data gathering and interpretation Making a diagnosis or decision Managing medical complexity Working in a team Continuous professional development Maintaining an ethical approach Fitness to practise Clinical examination and procedural skills Learning and development PCN Core values Awareness of the legal and ethical issues of the role Ability to work effectively in a multidisciplinary team as a key player Adult safeguarding level 3
Desirable
IT experience / computer skills Project management and leadership Experience of long term condition management eg diabetes, CVD, COPD Immunization experience
Experience Essential
Own transport and driving license, in order to be able to travel regularly between sites around West Southampton
Desirable
Previous Care Home Primary Care experience Background in community nursing
Qualifications Essential
Nursing qualification Current NMC Registration Membership of a professional body UK Driving license
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 Southampton West PCN Limited
Address Shirley Health Partnership
355 Shirley Road
Southampton
so15 3jd
United Kingdom
Employer's website https://www.southamptonwestpcn.co.uk/ (Opens in a new tab)