Job summary
The post holder will
play a crucial role in supporting Wallsend residents with frailty and complex
health needs. Working as part of a multidisciplinary team within primary care,
the role involves providing expert care, assessing frailty levels, implementing
person-centred care plans, and promoting proactive and preventative healthcare
approaches. Working with individuals, families and
wider community to reduce frailty through thorough assessments and care plans
which include education and signposting eg. around reducing falls risks with
simple exercises, assessing bone density, reducing isolation, regular vision,
dental and hearing check, ensuring regular structured medication reviews.
Main duties of the job
- Deliver holistic nursing assessments and contribute to comprehensive geriatric assessments (CGA) in community settings (home visits, clinics, care homes).
- Acute Visiting Housebound visits.
- Develop, implement, and review personalised care plans that meet the physical, emotional, and social needs of frail older adults.
- Identify early signs of deterioration and implement proactive interventions to avoid hospital admissions where appropriate.
- Promote self-management and independence in patients with long-term conditions.
- Work collaboratively with the wider multidisciplinary teams.
- Provide health education to patients, families, and carers.
- Support in advanced care planning conversations where appropriate.
- COVID and flu vaccinations in Housebound Patients
- Maintain accurate and timely clinical records in accordance with local policies and standards.
- Participate in clinical supervision, audits, and service development initiatives.
About us
We are Wallsend Primary Care Network, we support the 3 GP
practices in Wallsend and 44,000 patients.
We have a team of Social Prescribers, Mental Health Nurses, Pharmacists,
First Contact Physio's and a Health and Wellbeing Coach who support the
patients in Wallsend.
Our priority is to deliver care which is personalised to the
needs of the patients of Wallsend Support our practices in any way we can to
ensure the best possible healthcare & access to local services. We
endeavour to make the best use of our resources to ensure that every one of our
patients gets the help and support that they need and deserve.
Job description
Job responsibilities
MANAGEMENT OF PATIENT HEALTH AND ILLNESS
- To deliver a high standard of patient care using advanced autonomous clinical skills, and a broad and in-depth knowledge base
- Conduct comprehensive frailty assessments using evidence based tools
- Develop, implement, and evaluate individualised care plans in collaboration with residents, families, and other professionals
- Provide expert care, including Care Planning, medication optimisation and symptom control for long-term conditions.
- Provide on the day assessment of acute presentations of illnesses.
- Monitor and manage deteriorating conditions, implementing escalation plans where necessary, eg with on call duty GP at relevant practice, admission to hospital or further discussion with appropriate colleagues.
- Lead on advanced care planning, ensuring patients preferences and best interests are prioritised.
- Work closely with professionals in practices, wider primary care and community teams in identification of potentially frail patients and work within those MDTs to optimise management.
- Instigate necessary invasive and non-invasive diagnostic tests or investigations, interpret and manage findings/reports.
- Where the post holder is an independent prescriber: to prescribe safe, effective, and appropriate medication as defined by current legislative framework. If not an independent prescriber willing to work towards this.
- To prioritise health problems and intervene appropriately, including initiation of effective emergency care.
- Promote health and well-being using health promotion, health education, screening, and therapeutic communication skills
- To clearly communicate the health status of the patient using appropriate terminology, technology, and format.
- Covid and Flu Vaccinations in Housebound patients.
- Provide safe, evidence-based, cost-effective, individualised patient care.
- To work within practice guidelines, policies, and protocols.
- To maintain accurate and contemporaneous records, utilising computer systems where appropriate and consider the Caldicott Principles in relation to all data handling.
PROFESSIONAL ROLE
- To promote personal development and clinical excellence.
- Working with the clinical team and others in developing new roles, responding to changing healthcare needs.
- To facilitate and participate in multi-disciplinary education and clinical supervision.
- To work within your regulatory body Code of Practice including maintaining professional development.
- Participate in organisational decision making, interpret variations in outcomes and use data from information systems to improve practice.
- To promote evidence-based practice using the latest research-based guidelines and the development of practice-based research.
- Monitor the effectiveness of their clinical practice through the quality assurance strategies such as the use of audit and peer review.
- Participate in continuing professional development opportunities to ensure that up-to-date evidence-based knowledge and competence in all aspects of the role is maintained
- Keep up to date with pertinent health-related policy and work with the practice team to consider the impact and strategies for implementation.
- Pro-actively promote the Ageing well service within the Practices and externally to key stakeholders and agencies
- To play an active role in the development of practice development plans and new services.
TEAM ROLE
- As a clinician be available to support other healthcare team members and to accept referrals from other team members.
- To liaise with all members of the Primary Health Care Team and other agencies local authority, social services, secondary care, voluntary sector, and Clinical Commissioning Group in order to assure appropriate care is provided for the practice population.
- To participate as a key member of the multi-professional team through the development of collaborative and innovative practice.
- To value all team members.
- To support practices with their CQC responsibilities eg Long Term Condition Review of Housebound Patients
ORGANISATIONAL- To complete records, audits, reports and respond to appropriate questions and requests.
- To attend meetings as requested.
- Support effective communication channels between the whole team.
- Develop a sound understanding of the appointments database, event scheduling, session planning and essential practice cover needs.
- To keep the PCN Management team informed about pressures and difficulties or problem areas which may arise.
- To contribute to PCN strategy and training when requested.
- To work according to Clinical Governance and support the Clinical Governance Agenda.
- Engage and lead on significant event investigations.
- The individual will be required to undertake the assessment and management of patients within the home environment.
MISSION, VALUES AND STRATEGIC DIRECTION
- Wallsend PCN are a friendly, approachable and collaborative organisation and we pride ourselves on having staff that follow this vision. We are looking for a colleague who will follow this ethos.
- Ensure that patient centred care and safety is central to the culture, philosophy, and organisation of the PCN.
- To encourage and support patients with long term conditions to develop their ability to self manage.
- To develop a culture of ongoing review, considering new methods of working.
CODES OF CONDUCT AND ACCOUNTABILITY
- To always work within the highest levels of standards commensurate with the post.
HEALTH AND SAFETY
- The post holder must comply with the PCN's Health and Safety Policy, by following agreed safe working procedures and report incidents using the organisations Incident Reporting System. Specifically, they must:
- Comply with any safety instructions.
- Use in a proper and safe the equipment and facilities provided.
- Refrain from the wilful misuse or interference with anything provided in the interest of health and safety.
- Report as soon as practical any hazards and defects.
- Report as soon as practical, accidents and untoward occurrences and ensure that accident forms are completed.
EMPLOYMENT ACTS AND CODES OF PRACTICE
- Comply with employment legislation and codes of good practice.
CLINICAL GOVERNANCE
- To be familiar with and comply with each Practices Clinical Governance standards, policies and procedures.
Job description
Job responsibilities
MANAGEMENT OF PATIENT HEALTH AND ILLNESS
- To deliver a high standard of patient care using advanced autonomous clinical skills, and a broad and in-depth knowledge base
- Conduct comprehensive frailty assessments using evidence based tools
- Develop, implement, and evaluate individualised care plans in collaboration with residents, families, and other professionals
- Provide expert care, including Care Planning, medication optimisation and symptom control for long-term conditions.
- Provide on the day assessment of acute presentations of illnesses.
- Monitor and manage deteriorating conditions, implementing escalation plans where necessary, eg with on call duty GP at relevant practice, admission to hospital or further discussion with appropriate colleagues.
- Lead on advanced care planning, ensuring patients preferences and best interests are prioritised.
- Work closely with professionals in practices, wider primary care and community teams in identification of potentially frail patients and work within those MDTs to optimise management.
- Instigate necessary invasive and non-invasive diagnostic tests or investigations, interpret and manage findings/reports.
- Where the post holder is an independent prescriber: to prescribe safe, effective, and appropriate medication as defined by current legislative framework. If not an independent prescriber willing to work towards this.
- To prioritise health problems and intervene appropriately, including initiation of effective emergency care.
- Promote health and well-being using health promotion, health education, screening, and therapeutic communication skills
- To clearly communicate the health status of the patient using appropriate terminology, technology, and format.
- Covid and Flu Vaccinations in Housebound patients.
- Provide safe, evidence-based, cost-effective, individualised patient care.
- To work within practice guidelines, policies, and protocols.
- To maintain accurate and contemporaneous records, utilising computer systems where appropriate and consider the Caldicott Principles in relation to all data handling.
PROFESSIONAL ROLE
- To promote personal development and clinical excellence.
- Working with the clinical team and others in developing new roles, responding to changing healthcare needs.
- To facilitate and participate in multi-disciplinary education and clinical supervision.
- To work within your regulatory body Code of Practice including maintaining professional development.
- Participate in organisational decision making, interpret variations in outcomes and use data from information systems to improve practice.
- To promote evidence-based practice using the latest research-based guidelines and the development of practice-based research.
- Monitor the effectiveness of their clinical practice through the quality assurance strategies such as the use of audit and peer review.
- Participate in continuing professional development opportunities to ensure that up-to-date evidence-based knowledge and competence in all aspects of the role is maintained
- Keep up to date with pertinent health-related policy and work with the practice team to consider the impact and strategies for implementation.
- Pro-actively promote the Ageing well service within the Practices and externally to key stakeholders and agencies
- To play an active role in the development of practice development plans and new services.
TEAM ROLE
- As a clinician be available to support other healthcare team members and to accept referrals from other team members.
- To liaise with all members of the Primary Health Care Team and other agencies local authority, social services, secondary care, voluntary sector, and Clinical Commissioning Group in order to assure appropriate care is provided for the practice population.
- To participate as a key member of the multi-professional team through the development of collaborative and innovative practice.
- To value all team members.
- To support practices with their CQC responsibilities eg Long Term Condition Review of Housebound Patients
ORGANISATIONAL- To complete records, audits, reports and respond to appropriate questions and requests.
- To attend meetings as requested.
- Support effective communication channels between the whole team.
- Develop a sound understanding of the appointments database, event scheduling, session planning and essential practice cover needs.
- To keep the PCN Management team informed about pressures and difficulties or problem areas which may arise.
- To contribute to PCN strategy and training when requested.
- To work according to Clinical Governance and support the Clinical Governance Agenda.
- Engage and lead on significant event investigations.
- The individual will be required to undertake the assessment and management of patients within the home environment.
MISSION, VALUES AND STRATEGIC DIRECTION
- Wallsend PCN are a friendly, approachable and collaborative organisation and we pride ourselves on having staff that follow this vision. We are looking for a colleague who will follow this ethos.
- Ensure that patient centred care and safety is central to the culture, philosophy, and organisation of the PCN.
- To encourage and support patients with long term conditions to develop their ability to self manage.
- To develop a culture of ongoing review, considering new methods of working.
CODES OF CONDUCT AND ACCOUNTABILITY
- To always work within the highest levels of standards commensurate with the post.
HEALTH AND SAFETY
- The post holder must comply with the PCN's Health and Safety Policy, by following agreed safe working procedures and report incidents using the organisations Incident Reporting System. Specifically, they must:
- Comply with any safety instructions.
- Use in a proper and safe the equipment and facilities provided.
- Refrain from the wilful misuse or interference with anything provided in the interest of health and safety.
- Report as soon as practical any hazards and defects.
- Report as soon as practical, accidents and untoward occurrences and ensure that accident forms are completed.
EMPLOYMENT ACTS AND CODES OF PRACTICE
- Comply with employment legislation and codes of good practice.
CLINICAL GOVERNANCE
- To be familiar with and comply with each Practices Clinical Governance standards, policies and procedures.
Person Specification
Key Competencies & Skills
Essential
- Excellent communication and interpersonal skills to engage with patients, families, and healthcare professionals.
- Ability to work autonomously and collaboratively within a primary care setting.
- Strong problem solving and clinical reasoning abilities.
- Compassionate, patient-centred approach to care delivery.
- Willing to work as part of a team and understands the importance of a happy team.
- Ability to adapt to the clinical priorities of the day
- IT proficiency and experience with electronic patient records.
- Willingness to work flexibly across service hours
Qualifications
Essential
- Registered clinician with relevant experience in care in the community, elderly care, or frailty services.
- Strong clinical assessment and decision-making skills in managing frailty and complex needs.
- Independent prescribing qualification V300 or willingness to undertake training.
- Experience of working in a multi-disciplinary team, liaising with primary and secondary care.
- Awareness of the importance of frailty.
- Ability to deliver training and support staff where appropriate.
- Experience in assessing and managing acute and chronic illness presentations.
- Clean Driving Licence and own car.
- Enhanced DBS Check
Desirable
- Advanced Clinical Practice qualification or working towards it.
- Experience in quality improvement and service development.
- Understanding of local and national policies related to frailty and older peoples care.
- Knowledge of frailty assessment tools, end-of-life care planning, and chronic disease management.
- Experience within Primary Care.
Person Specification
Key Competencies & Skills
Essential
- Excellent communication and interpersonal skills to engage with patients, families, and healthcare professionals.
- Ability to work autonomously and collaboratively within a primary care setting.
- Strong problem solving and clinical reasoning abilities.
- Compassionate, patient-centred approach to care delivery.
- Willing to work as part of a team and understands the importance of a happy team.
- Ability to adapt to the clinical priorities of the day
- IT proficiency and experience with electronic patient records.
- Willingness to work flexibly across service hours
Qualifications
Essential
- Registered clinician with relevant experience in care in the community, elderly care, or frailty services.
- Strong clinical assessment and decision-making skills in managing frailty and complex needs.
- Independent prescribing qualification V300 or willingness to undertake training.
- Experience of working in a multi-disciplinary team, liaising with primary and secondary care.
- Awareness of the importance of frailty.
- Ability to deliver training and support staff where appropriate.
- Experience in assessing and managing acute and chronic illness presentations.
- Clean Driving Licence and own car.
- Enhanced DBS Check
Desirable
- Advanced Clinical Practice qualification or working towards it.
- Experience in quality improvement and service development.
- Understanding of local and national policies related to frailty and older peoples care.
- Knowledge of frailty assessment tools, end-of-life care planning, and chronic disease management.
- Experience within Primary Care.
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.
