PCN Frailty Specialist Nurse

Lakeside Healthcare Group

Information:

This job is now closed

Job summary

Four Counties PCN are looking to expand our team with an enthusiastic Nurse, with a specific or specialist interest in frailty, accompanied with a passion for elderly care and multidisciplinary team working. You will be working flexibly across all four Enhanced Health in Care Homes (EHCH) DES workstreams, with a predominant focus on advanced care planning and providing proactive preventative care.

1. Enhanced primary care support

2. Multi-disciplinary team (MDT) support

3. Falls prevention, Reablement, and rehabilitation

4. High quality palliative and end-of-life care, Mental health, and dementia care

The successful candidate will be working alongside a highly skilled and growing multi-disciplinary team to help deliver the above on behalf of two GP practices as part of the Primary Care Network.

Main duties of the job

The successful candidate will work closely with the GPs, Community Services, Occupational Therapists, Care Coordinators and to provide fast reactive services for patients with exacerbation of long-term conditions and/or frailty, ensure rapid delivery of treatment, care planning and admission avoidance where appropriately possible.

They will provide assessment and care planning including history taking, physical assessment and treatment planning, without direct supervision, and delegate appropriate tasks to Associate Practitioners and Health Care Support Workers and offer clinical supervision to support them in their role.

Responsibilities

  • Person Centred Care Planning- By having a person-centred care approach it gives people more choice and control in their lives by providing an approach that is appropriate to the individual's needs. It involves a conversation shift from asking 'what's the matter with you' to 'what matters to you'.
  • Monitor and lead improvements to standards of care through, supervision of practice, clinical audit, evidence-based practice, teaching and supporting professional colleagues and the provision of skilled professional leadership
  • Provide high quality mental health and dementia care, offering support and guidance to homes, working in collaboration with community services

About us

LAKESIDE HEALTHCARE is changing the face of primary care provision in England. We are bold, adventurous, ambitious and determined to thrive in uncertain times. We are the largest true partnership in the NHS and operate from various sites across the East Midlands. We serve the healthcare needs of over 170,000 patients across Northamptonshire, Lincolnshire & Cambridgeshire, operating services for 4 Primary Care Networks (PCN) across our geography. Joining our team presents an opportunity to be part of a large organisation that is changing the way primary care is delivered today, focussed on local needs at a PCN level.

About the Practice/Department/Team

Four Counties PCN serves a population of approximately 44 000 residents across Bourne, Stamford and surrounding villages. We have named the PCN Four Counties as we support residents across Lincolnshire, Rutland, Northamptonshire, and Cambridgeshire.

As part of our Primary Care Network, we have nine Care Homes which offer Residential, Nursing and Dementia Care. Over the last 6 months we have established strong working relationships with our care homes and have introduced several key roles such as Clinical Pharmacists, Occupational therapists, Social Prescribing link workers and GPs. Recently appointed Care Coordinators and a Frailty Specialist Nurse will complement and complete a strong forming multidisciplinary team.

Date posted

18 October 2021

Pay scheme

Other

Salary

Depending on experience

Contract

Permanent

Working pattern

Full-time, Part-time

Reference number

A3007-21-6136

Job locations

Ryhall Road

Stamford

Lincolnshire

PE9 1YA


Job description

Job responsibilities

Job summary

Four Counties Primary Care Network are establishing a collaborative multi-disciplinary service providing proactive Primary Care to our large Care Home population in Stamford, Bourne and villages. We are delivering four main workstreams on behalf of the 2 GP practices as part of the Enhanced Health in Care Home DES:

1. Enhanced primary care support

2. Multi-disciplinary team (MDT) support

3. Falls prevention, Reablement, and rehabilitation

4. High quality palliative and end-of-life care, Mental health, and dementia care

We are looking to expand our team with an enthusiastic Nurse, with a special interest in frailty, and passion for elderly care and multidisciplinary team working. You will be working flexibly across all four workstreams, but with a main focus on advanced care planning and providing proactive preventative care.

About us

Primary Care Networks (PCNs) are groups of GP practices working together with other local organisations, such as community, mental health, social care, pharmacy, hospital, voluntary services and care homes. Together we support the needs of a population that has grown, is living longer, and may need to access local health services more often.

4 Counties PCN serves a population of approximately 44 000 residents across Bourne, Stamford and villages. We have named the PCN 4 Counties as we support residents across Lincolnshire, Rutland, Northamptonshire and Cambridgeshire. As part of our Primary Care Network we have 9 Care Homes which offer Residential, Nursing and Dementia Care. Over the last 6 months we have established strong working relationships with our care homes and have introduced a number of key roles such as Clinical Pharmacists, Occupational therapists, Social Prescribing link workers and GPs. Care Coordinators and a Frailty Specialist Nurse will complement and complete a strong, forming multidisciplinary team.

The PCN is led by Miles Langdon Clinical Director, Katie Clark PCN business manager and operationally supported by Natalie Munslow Neighbourhood Lead, it is an exciting time to join us on our journey of transforming care for this population.

Key Responsibilities

  • Identify and support educational opportunities to work with care homes, for example completion of Respect Documents
  • Person Centred Care Planning- By having a person-centred care approach it gives people more choice and control in their lives by providing an approach that is appropriate to the individual's needs. It involves a conversation shift from asking 'what's the matter with you' to 'what matters to you'.
  • Early identification and recognition of deterioration to include proactive care and escalation planning
  • Full Comprehensive Geriatric assessment for residents that have moderate to severe Frailty to support the coordination of care with community and urgent care services
  • Understand the degree of frailty, mild moderate or severe and the 6 frailty syndromes enabling the correct proportionate response to a patient need
  • To support proactive, anticipatory and advance care planning using an agreed set of validated, evident based assessment tools to help identify the degree of need. Edmonton, SPICT/SPICT4ALL, Respect, RNT, CGA, EPaCCS
  • Monitor and lead improvements to standards of care through, supervision of practice, clinical audit, evidence-based practice, teaching and supporting professional colleagues and the provision of skilled professional leadership.
  • Provide hydration and nutritional support
  • Support good Oral Health Care
  • Working with other practitioners and agencies within the Primary Care Network and local system as necessary to develop patient specific treatment plans and ensure Care Pathways are utilised. Attendance through MDT working
  • Provide continence support and management in conjunction with homes and community services
  • Support necessary vaccination campaigns within care homes
  • Provide high quality mental health and dementia care, offering support and guidance to homes, working in collaboration with community services
  • Provide wound care support and advice in conjunction with homes and community services
  • Take a lead role in developing and delivering the Enhanced Health in Care Homes DES.
  • Undertake high standards of clinical record keeping including electronic data entry and recording of patient records.

Communication

  • Utilise and demonstrate sensitive communication styles, to ensure patients are fully informed and consent to treatment
  • Communicate with and support patients who are receiving bad news
  • Communicate effectively with patients and carers, recognising the need for alternative methods of communication to overcome different levels of understanding, cultural background, and preferred ways of communicating
  • Anticipate barriers to communication and take action to improve communication
  • Maintain effective communication within the practice environment and with external stakeholders
  • Act as an advocate for patients and colleagues
  • Ensure awareness of sources of support and guidance (e.g. PALS) and provide information in an acceptable format to all patients, recognising any difficulties and referring where appropriate

Delivering a quality service

  • Recognise and work within own competence and professional code of conduct as regulated by the NMC
  • Produce accurate, contemporaneous, and complete records of patient consultations, consistent with legislation, policies, and procedures
  • Prioritise, organise, and manage own workload in a manner that maintains and promotes quality
  • Deliver evidence-based care according to NICE and other recognised national guidelines
  • Assess effectiveness of care delivery through self and peer review, benchmarking, and formal evaluation
  • Initiate and participate in the maintenance of quality governance systems and processes across the organisation and its activities
  • Utilise the clinical audit cycle as a means of evaluating the quality of the work of self and the team, implementing improvements where required
  • In partnership with other clinical teams, collaborate on improving the quality of health care responding to local and national policies and initiatives as appropriate
  • Evaluate patients response to health care provision and the effectiveness of care
  • Support and participate in shared learning across the practice, PCN and wider locality and organisation
  • Use a structured framework (ego root-cause analysis) to manage, review and identify learning from patient complaints, clinical incidents and near-miss events
  • Assess the impact of policy implementation on care delivery
  • Approve the performance of the team, providing feedback as appropriate
  • Understand and apply legal issues that support the identification of vulnerable and abused children and adults and be aware of statutory child/vulnerable patients health procedures and local guidance
  • Ensure the whole team has skills and knowledge regarding domestic violence, vulnerable adults, substance abuse and addictive behaviour. Provide guidance and support to ensure appropriate referral if required

Leadership personal and people development

  • Take responsibility for own learning and performance including participating in clinical supervision and acting as a positive role mode
  • Support staff development to maximise potential
  • Actively promote the workplace as a learning environment, encouraging everyone to learn from each other and from external good practice
  • Encourage others to make realistic self-assessment of their application of knowledge and skills, challenging any complacency or actions that are not in the interest of the public and/or users of services
  • Critically evaluate and review innovations and developments that are relevant to the area of work
  • Take a lead role in planning and implementing changes within the area of care andResponsibility
  • Work with practice management to ensure sufficient staff of appropriate ability, quality and Skill-mix are available to meet current and future service delivery, that selection and recruitment processes are effective and that equality of treatment of the team incorporates quality HR principles and processes
  • Contribute to the development of local guidelines, protocols, and standards.
  • Maintain effective communication with those responsible for the overall commissioning and procurement process
  • Maintain active involvement in the planning and processes of practice-based commissioning or similar initiatives

Job description

Job responsibilities

Job summary

Four Counties Primary Care Network are establishing a collaborative multi-disciplinary service providing proactive Primary Care to our large Care Home population in Stamford, Bourne and villages. We are delivering four main workstreams on behalf of the 2 GP practices as part of the Enhanced Health in Care Home DES:

1. Enhanced primary care support

2. Multi-disciplinary team (MDT) support

3. Falls prevention, Reablement, and rehabilitation

4. High quality palliative and end-of-life care, Mental health, and dementia care

We are looking to expand our team with an enthusiastic Nurse, with a special interest in frailty, and passion for elderly care and multidisciplinary team working. You will be working flexibly across all four workstreams, but with a main focus on advanced care planning and providing proactive preventative care.

About us

Primary Care Networks (PCNs) are groups of GP practices working together with other local organisations, such as community, mental health, social care, pharmacy, hospital, voluntary services and care homes. Together we support the needs of a population that has grown, is living longer, and may need to access local health services more often.

4 Counties PCN serves a population of approximately 44 000 residents across Bourne, Stamford and villages. We have named the PCN 4 Counties as we support residents across Lincolnshire, Rutland, Northamptonshire and Cambridgeshire. As part of our Primary Care Network we have 9 Care Homes which offer Residential, Nursing and Dementia Care. Over the last 6 months we have established strong working relationships with our care homes and have introduced a number of key roles such as Clinical Pharmacists, Occupational therapists, Social Prescribing link workers and GPs. Care Coordinators and a Frailty Specialist Nurse will complement and complete a strong, forming multidisciplinary team.

The PCN is led by Miles Langdon Clinical Director, Katie Clark PCN business manager and operationally supported by Natalie Munslow Neighbourhood Lead, it is an exciting time to join us on our journey of transforming care for this population.

Key Responsibilities

  • Identify and support educational opportunities to work with care homes, for example completion of Respect Documents
  • Person Centred Care Planning- By having a person-centred care approach it gives people more choice and control in their lives by providing an approach that is appropriate to the individual's needs. It involves a conversation shift from asking 'what's the matter with you' to 'what matters to you'.
  • Early identification and recognition of deterioration to include proactive care and escalation planning
  • Full Comprehensive Geriatric assessment for residents that have moderate to severe Frailty to support the coordination of care with community and urgent care services
  • Understand the degree of frailty, mild moderate or severe and the 6 frailty syndromes enabling the correct proportionate response to a patient need
  • To support proactive, anticipatory and advance care planning using an agreed set of validated, evident based assessment tools to help identify the degree of need. Edmonton, SPICT/SPICT4ALL, Respect, RNT, CGA, EPaCCS
  • Monitor and lead improvements to standards of care through, supervision of practice, clinical audit, evidence-based practice, teaching and supporting professional colleagues and the provision of skilled professional leadership.
  • Provide hydration and nutritional support
  • Support good Oral Health Care
  • Working with other practitioners and agencies within the Primary Care Network and local system as necessary to develop patient specific treatment plans and ensure Care Pathways are utilised. Attendance through MDT working
  • Provide continence support and management in conjunction with homes and community services
  • Support necessary vaccination campaigns within care homes
  • Provide high quality mental health and dementia care, offering support and guidance to homes, working in collaboration with community services
  • Provide wound care support and advice in conjunction with homes and community services
  • Take a lead role in developing and delivering the Enhanced Health in Care Homes DES.
  • Undertake high standards of clinical record keeping including electronic data entry and recording of patient records.

Communication

  • Utilise and demonstrate sensitive communication styles, to ensure patients are fully informed and consent to treatment
  • Communicate with and support patients who are receiving bad news
  • Communicate effectively with patients and carers, recognising the need for alternative methods of communication to overcome different levels of understanding, cultural background, and preferred ways of communicating
  • Anticipate barriers to communication and take action to improve communication
  • Maintain effective communication within the practice environment and with external stakeholders
  • Act as an advocate for patients and colleagues
  • Ensure awareness of sources of support and guidance (e.g. PALS) and provide information in an acceptable format to all patients, recognising any difficulties and referring where appropriate

Delivering a quality service

  • Recognise and work within own competence and professional code of conduct as regulated by the NMC
  • Produce accurate, contemporaneous, and complete records of patient consultations, consistent with legislation, policies, and procedures
  • Prioritise, organise, and manage own workload in a manner that maintains and promotes quality
  • Deliver evidence-based care according to NICE and other recognised national guidelines
  • Assess effectiveness of care delivery through self and peer review, benchmarking, and formal evaluation
  • Initiate and participate in the maintenance of quality governance systems and processes across the organisation and its activities
  • Utilise the clinical audit cycle as a means of evaluating the quality of the work of self and the team, implementing improvements where required
  • In partnership with other clinical teams, collaborate on improving the quality of health care responding to local and national policies and initiatives as appropriate
  • Evaluate patients response to health care provision and the effectiveness of care
  • Support and participate in shared learning across the practice, PCN and wider locality and organisation
  • Use a structured framework (ego root-cause analysis) to manage, review and identify learning from patient complaints, clinical incidents and near-miss events
  • Assess the impact of policy implementation on care delivery
  • Approve the performance of the team, providing feedback as appropriate
  • Understand and apply legal issues that support the identification of vulnerable and abused children and adults and be aware of statutory child/vulnerable patients health procedures and local guidance
  • Ensure the whole team has skills and knowledge regarding domestic violence, vulnerable adults, substance abuse and addictive behaviour. Provide guidance and support to ensure appropriate referral if required

Leadership personal and people development

  • Take responsibility for own learning and performance including participating in clinical supervision and acting as a positive role mode
  • Support staff development to maximise potential
  • Actively promote the workplace as a learning environment, encouraging everyone to learn from each other and from external good practice
  • Encourage others to make realistic self-assessment of their application of knowledge and skills, challenging any complacency or actions that are not in the interest of the public and/or users of services
  • Critically evaluate and review innovations and developments that are relevant to the area of work
  • Take a lead role in planning and implementing changes within the area of care andResponsibility
  • Work with practice management to ensure sufficient staff of appropriate ability, quality and Skill-mix are available to meet current and future service delivery, that selection and recruitment processes are effective and that equality of treatment of the team incorporates quality HR principles and processes
  • Contribute to the development of local guidelines, protocols, and standards.
  • Maintain effective communication with those responsible for the overall commissioning and procurement process
  • Maintain active involvement in the planning and processes of practice-based commissioning or similar initiatives

Person Specification

Qualifications

Essential

  • Recognised professional degree
  • Registered with NMC
  • Teaching qualification

Desirable

  • Post registration course in palliative care, dementia, long term conditions or frailty
Person Specification

Qualifications

Essential

  • Recognised professional degree
  • Registered with NMC
  • Teaching qualification

Desirable

  • Post registration course in palliative care, dementia, long term conditions or frailty

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).

Additional information

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

Lakeside Healthcare Group

Address

Ryhall Road

Stamford

Lincolnshire

PE9 1YA


Employer's website

https://www.lakesidehealthcaregroup.co.uk (Opens in a new tab)


Employer details

Employer name

Lakeside Healthcare Group

Address

Ryhall Road

Stamford

Lincolnshire

PE9 1YA


Employer's website

https://www.lakesidehealthcaregroup.co.uk (Opens in a new tab)


For questions about the job, contact:

Date posted

18 October 2021

Pay scheme

Other

Salary

Depending on experience

Contract

Permanent

Working pattern

Full-time, Part-time

Reference number

A3007-21-6136

Job locations

Ryhall Road

Stamford

Lincolnshire

PE9 1YA


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