Job responsibilities
Clinical Care
Deliver safe, effective, and evidence-based clinical care to housebound patients and care home residents, in line with the Enhanced Health in Care Homes (EHCH) requirements of the Primary Care Network (PCN) Directed Enhanced Service (DES).
Manage an autonomous caseload of acute, chronic, and proactive patients, ensuring timely assessment, intervention, and follow-up under the direction and clinical governance of the Home Visiting Service (HVS) Leads and Clinical Director(s).
Provide compassionate, person-centred care that holistically addresses physical, psychological, emotional, and social needs.
Undertake advanced clinical assessments, formulate differential diagnoses, and implement evidence-based management plans within scope of practice.
Conduct structured medication reviews and deliver safe, effective independent prescribing in accordance with national and local governance frameworks.
Participate in medicines optimisation initiatives, including deprescribing, polypharmacy reviews, and the promotion of safe prescribing practices for frail and older adults.
Develop, implement, and evaluate personalised care and support plans (PCSPs) that reflect patient preferences, goals, and clinical priorities.
Carry out comprehensive frailty and functional assessments, identifying risks of deterioration and taking proactive action to prevent crisis or hospital admission.
Deliver targeted health promotion and preventative interventions that optimise health, reduce inequality, and support independence.
Participate in scheduled care home rounds and proactive visits, ensuring continuity and coordination of care across the MDT and wider system.
Support and lead the delivery of national vaccination and immunisation programmes for care home residents and housebound patients.
Undertake long-term condition reviews in line with Quality and Outcomes Framework (QOF) and local enhanced service requirements.
Provide palliative and end-of-life care, including advance care planning and symptom management, in accordance with best practice and patient wishes.
Collaborate with care home staff, GPs, community teams, and other professionals to ensure integrated, coordinated care across the EHCH pathway.
Provide clinical leadership, mentorship, and support to colleagues within the multidisciplinary team, contributing to skill development and professional growth.
Education, Support, and Empowerment
Deliver education, advice, and clinical support to care home and domiciliary staff to enhance understanding of frailty, medicines safety, and early recognition of deterioration.
Support carers and families by providing guidance, reassurance, and tools to promote patients, both acute and proactive.
Coordination & Collaboration
Work collaboratively with community, primary care, and social care teams to ensure integrated, person-centred care delivery.
Liaise with partner organisations, including the voluntary and community sector, to enhance the support available for residents and carers.
Participate in and contribute to MDT meetings, care home rounds, and case conferences, supporting shared decision-making and continuity of care.
Promote effective communication and coordination between general practice, community nursing, pharmacy, mental health, and therapy services to deliver seamless care.
Professional Practice
Maintain accurate, timely, and comprehensive clinical documentation in line with professional, legal, and organisational standards.
Adhere to all relevant NHS, PCN, and NMC / HCPC policies, procedures, and codes of conduct.
Communicate clearly and sensitively when handling complex, confidential, or contentious information, demonstrating empathy and professionalism.
Apply de-escalation and conflict resolution strategies when necessary, maintaining a transparent and open culture in line with the Duty of Candour.
Participate in clinical supervision, reflective practice, and continuous professional development to ensure safe and effective practice.
Confidentiality
Respect the confidentiality and privacy of patients, carers, and colleagues at all times.
Handle all information in accordance with Data Protection legislation, PCN policies, and NHS information governance requirements.
Disclose patient or organisational information only to authorised personnel, as permitted by policy or legal duty.
Health and Safety
Ensure compliance with PCN and practice Health and Safety policies.
Identify, report, and act upon any health and safety or infection prevention concerns promptly.
Maintain current knowledge of infection prevention and control and apply best practice in all care settings.
Participate in relevant training and promote a culture of safety, wellbeing, and continuous learning within the team.
Equality and Diversity
Promote equality, diversity, and inclusion in all aspects of care delivery and professional interaction.
Respect the individuality, dignity, and cultural values of patients, carers, and colleagues.
Ensure care is person-centred, non-judgemental, and accessible to all.
Personal and Professional Development
Engage in ongoing professional development and annual appraisal, maintaining a portfolio of learning and competency evidence.
Actively seek opportunities for role development within the EHCH framework and share expertise with colleagues through mentoring and education.
Participate in PCN training, quality improvement, and innovation initiatives.
Governance
Support the PCN to ensure it can meet all contractual and quality obligations related to the EHCH service within the PCN DES.
Record, investigate, and support resolution of complaints in accordance with NHS Complaints Regulations.
Promote and uphold high standards of governance, safety, and clinical effectiveness across the network.
Quality and Improvement
Contribute to the continuous improvement of EHCH and community services by sharing learning, feedback, and best practice.
Support quality improvement projects that enhance patient outcomes and service efficiency.
Foster a positive, collaborative culture within the PCN, encouraging innovation, teamwork, and system-wide learning.
Note: This job description is not exhaustive and may be amended in line with service developments, patient needs, or PCN priorities. The post-holder may be required to undertake additional duties commensurate with the role and level of responsibility.
