Specialist Neighbourhood Nurse

Job summary

The role is to support both the practice staff & the Neighbourhood Team to identify and support people to reduce the risk of unplanned hospital admissions, effectively support those individuals in the community,to focus on proactively case managing people and being the preferred point of contact for the patient and Neighbourhood Team in order to achieve the following objectives:

Be a proactive member of the Neighbourhood Team

Provision of safe alternatives to Secondary Care services

Proactively identify vulnerable and at-risk patient groups and defines responsive, appropriate and timely management

Improvement in the quality of clinical care and outcomes for our patients

Holistic and personalised care planning which supports people and their carer(s) to be involved in the planning of their care, to live well, self-manage independently and have systems in place to support them during crisis/exacerbation of their condition.

Integrated team working, as part of the delivery of Integrated Neighbourhood Teams, between providers of care and support to ensure people receive the right care, at the right time, by the right people and transitions are seamless with reduced barriers, duplication, inefficiencies and silo working.

This list is not exhaustive.

Main duties of the job

Main duties and responsibilities

To liaise with the registered GP & all other providers and services utilising, where appropriate, a multi-disciplinary approach.

To implement & review individual care plans, a self-management plans

Contact people following an unplanned hospital admission & those with a history of repeat admissions,

Develop & maintain a detailed knowledge of local services to enable supported signposting of people with identified need, sharing information with the Neighbourhood Team.

Liaise with GPs and practice teams to identify people who are elderly, frail or who have long term health needs & support.

Identify people at risk of loss of independence or admission to hospital as a result of inadequate social support.

Implement PCSP for individual people, ensuring preventative actions are detailed to support the appropriate use of services.

Identify when urgent action or a step up in care is required & promptly alert the relevant member of the Neighbourhood Team, highlighting any safety concerns.

Undertake visits or telephone contact to manage people on the SNNs case load following any unplanned hospital admissions where appropriate.

Participate & in some situations, lead the Neighbourhood multi-disciplinary meetings, this includes GSF meetings, Neighbourhood MDT, Palliative Care huddles etc

Maintain accurate & up to date records of patient contacts

Support the Primary Care Network Manager in providing KPI reports for submission as requested.

This list is not exhaustive.

About us

Spalding PCN comprise of 2 large practices in Spalding. This role is based at Munro Medical Centre.

We work from purpose built premises and have a small branch site in the village of Pinchbeck, we use SystmOne as our clinical system. We employ 70+ staff and in addition to the nursing team we have a variety of other supporting clinicians and administration staff. We are a busy practice , but we have excellent systems in place to support all clinicians in their day to day work.

We have regular practice/team/clinical governance meetings and are committed to patient safety and staff wellbeing.

One thing that is regularly fed-back to us from visitors/GP registrars/Locums etc is that we are a very friendly, organised and supportive team.