Job summary
The post holder will work closely with the
PCN Clinical Director, PCN Manager and other members of the PCN Board to
develop collaborative working partnerships with key primary care and
community stakeholders. With an emphasis on developing the frailty team and
providing support with severe and moderately severe patients some of whom are
in nursing/residential homes as well as housebound patients.
The post holder will contribute to
the development of new clinical roles and maximise capacity and capability
within the PCN workforce.
As the role requires travel
between our practices, Care Homes and Homebound patients, you must have
access to your own transport with a full driving licence.
We are looking for the role to start in September 2025.
Main duties of the job
Core Responsibilities
- Lead on the delivery of care provision to our frail and elderly populations including proactive Person-Centred Care Planning and collaborative working to deliver the Enhanced Health in Care Homes DES.
- 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
- Ability to prescribe and deprescribe as appropriate within caseload for acute and chronic conditions relating to frailty
- 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, evidence-based assessment tools to help identify the degree of need, e.g. Respect and EPaCCS
- Ordering, performing and interpreting relevant clinical test and investigations
- Providing expert frailty advice and guidance and education where necessary to medical, nursing and other MDT colleagues.
About us
We are really pleased that you have taken the time to
find out more about a role at BWM PCN LTD. There are some great benefits in
working for General Practice and this is a very exciting time for BWM PCN as we
go through a new stage of growth and development.
BWM PCN are a group of 3 practices that work together to deliver
excellent care to our patient population of 30,000. The PCN practices include
Beechtree Medical Centre, Hawthorn Surgery & Whitehall Surgery.
Bramley and Wortley Primary Care Network (BWM PCN) has an
exciting opportunity to expand the PCN team and are looking for a highly
motivated and enthusiastic PCN Frailty Advanced Nurse Practitioner to join the team. We
recognise the value that a PCN FrailtyAdvanced Nurse Practitioner can bring to our
practices and patients.
We offer a huge range of exciting and challenging
opportunities for people who are passionate about making a difference in
primary care and who have a desire to work with a wider range of community
stakeholders.
Job description
Job responsibilities
- Lead on the delivery of care provision to our frail and elderly populations including proactive Person-Centred Care Planning and collaborative working to deliver the Enhanced Health in Care Homes DES
- 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
- Ability to prescribe and deprescribe as appropriate within caseload for acute and chronic conditions relating to frailty
- 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, evidence-based assessment tools to help identify the degree of need, e.g. Respect and EPaCCS
- Ordering, performing and interpreting relevant clinical test and investigations
- Providing expert frailty advice and guidance and education where necessary to medical, nursing and other MDT colleagues.
- Assess and manage acute, chronic and acute on chronic conditions in relation to frailty to uphold patient safety and prevent admission where possible such as independently prescribing within competencies. Where admission avoidance is not possible, to independently and confidently liaise with secondary care colleagues as necessary
- 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.
- Identify and support educational opportunities to work with care homes, for example completion of Respect Documents, hydration and nutritional support and 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 service
- 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
- Undertake high standards of clinical record keeping including electronic data entry and recording of patient record
Job description
Job responsibilities
- Lead on the delivery of care provision to our frail and elderly populations including proactive Person-Centred Care Planning and collaborative working to deliver the Enhanced Health in Care Homes DES
- 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
- Ability to prescribe and deprescribe as appropriate within caseload for acute and chronic conditions relating to frailty
- 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, evidence-based assessment tools to help identify the degree of need, e.g. Respect and EPaCCS
- Ordering, performing and interpreting relevant clinical test and investigations
- Providing expert frailty advice and guidance and education where necessary to medical, nursing and other MDT colleagues.
- Assess and manage acute, chronic and acute on chronic conditions in relation to frailty to uphold patient safety and prevent admission where possible such as independently prescribing within competencies. Where admission avoidance is not possible, to independently and confidently liaise with secondary care colleagues as necessary
- 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.
- Identify and support educational opportunities to work with care homes, for example completion of Respect Documents, hydration and nutritional support and 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 service
- 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
- Undertake high standards of clinical record keeping including electronic data entry and recording of patient record
Person Specification
Experience
Essential
- Clinical Skills
- Ability to follow clinical procedures and instructions precisely under the supervision of nursing and medical staff
- Communication Skills
- Excellent communication skills, capable of effectively interacting with patients, families, and healthcare professionals
- Empathy and the ability to provide patient-centred care in a respectful and ethical manner
- Organisational Skills
- Strong organisational skills, able to manage multiple tasks efficiently and adapt to changing priorities
- Experience in managing patient appointments and maintaining accurate health records
- Teamwork
- Proven ability to work effectively as part of a healthcare team, supporting registered nurses and medical practitioners
- Personal Qualities
- High level of integrity and reliability
- Flexibility and willingness to learn new skills and undertake further training to meet the practices needs
- IT Proficiency
- Familiarity with SystmOne for recording and accessing patient information
- Additional Competencies
- Ability to handle sensitive information with discretion and to maintain confidentiality in accordance with GDPR
- Strong interpersonal skills, able to provide comfort and reassurance to patients undergoing stressful situations
Desirable
- Experience of working in primary care
- Experience of working in a GP practice
- Experience of working in a Care Home
Qualifications
Essential
- Professional registration with NMC or HCPC
- MSc in Advanced Clinical Practice or equivalent
- Post registration education encompassing assessment and clinical reasoning, diagnostics and independent non-medical prescribing
Desirable
- Post registration education/experience in frailty, care of the elderly, palliative care, dementia, long term conditions
Clinical Skills
Essential
- Professional registration with NMC or HCPC
- MSc in Advanced Clinical Practice (or equivalent)
- Post registration education encompassing: assessment and clinical reasoning, diagnostics and independent non-medical prescribingMinimum 5 years post registration experience, Experience with Palliative and End of life Care, Experience with Dementia Care, Experience in Personalised Care Planning, Experience in Frailty identification and Comprehensive Geriatric Assessments, Experience working in a multidisciplinary team
Desirable
- Post registration education/experience in frailty, care of the elderly, palliative care, dementia, long term conditions
Person Specification
Experience
Essential
- Clinical Skills
- Ability to follow clinical procedures and instructions precisely under the supervision of nursing and medical staff
- Communication Skills
- Excellent communication skills, capable of effectively interacting with patients, families, and healthcare professionals
- Empathy and the ability to provide patient-centred care in a respectful and ethical manner
- Organisational Skills
- Strong organisational skills, able to manage multiple tasks efficiently and adapt to changing priorities
- Experience in managing patient appointments and maintaining accurate health records
- Teamwork
- Proven ability to work effectively as part of a healthcare team, supporting registered nurses and medical practitioners
- Personal Qualities
- High level of integrity and reliability
- Flexibility and willingness to learn new skills and undertake further training to meet the practices needs
- IT Proficiency
- Familiarity with SystmOne for recording and accessing patient information
- Additional Competencies
- Ability to handle sensitive information with discretion and to maintain confidentiality in accordance with GDPR
- Strong interpersonal skills, able to provide comfort and reassurance to patients undergoing stressful situations
Desirable
- Experience of working in primary care
- Experience of working in a GP practice
- Experience of working in a Care Home
Qualifications
Essential
- Professional registration with NMC or HCPC
- MSc in Advanced Clinical Practice or equivalent
- Post registration education encompassing assessment and clinical reasoning, diagnostics and independent non-medical prescribing
Desirable
- Post registration education/experience in frailty, care of the elderly, palliative care, dementia, long term conditions
Clinical Skills
Essential
- Professional registration with NMC or HCPC
- MSc in Advanced Clinical Practice (or equivalent)
- Post registration education encompassing: assessment and clinical reasoning, diagnostics and independent non-medical prescribingMinimum 5 years post registration experience, Experience with Palliative and End of life Care, Experience with Dementia Care, Experience in Personalised Care Planning, Experience in Frailty identification and Comprehensive Geriatric Assessments, Experience working in a multidisciplinary team
Desirable
- Post registration education/experience in frailty, care of the elderly, palliative care, dementia, long term conditions
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
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).