Job responsibilities
Clinical practice
Manage a designated case load of
patients with chronic conditions, visiting them in their own home or consulting
with them at the practice.
Willing to oversee patients with a
variety of chronic and co-existing conditions including dementia, assist with
annual reviews as needed and manage exacerbations to avoid the need to be seen
by the acute team.
Assess as required their physical,
psychological and social needs to support self-management as much as possible
and avoid hospital admissions.
Work with patients in order to
support adherence to prescribed treatments and medications.
Work with Social Prescribing teams to
promote healthy lifestyles, and actively manager their health
Work with the Complex Care teams and
social care teams to manage the changing needs of the patient and their health
Attend multidisciplinary review
meetings to provide input and work collaboratively.
To promote safeguarding in line with
SHS policies and practices relating to Vulnerable Adult issues.
Ensure that accurate and up to date medical
records are kept according to legislation and confidentiality and the NMC code
of conduct.
Ensure that all new guidance and
evidence is implemented and shared with the multi-disciplinary team
·
Complete all training and practice updates and contribute to the shared
learning within the practice and across SHS.
Communication
Ensure effective and clear
communication with patients, family and carers in a timely fashion.
Recognise the need for alternative
methods of communication to overcome differing levels of understanding, culture
and preferred ways of communication.
Act as an advocate for patients and
colleagues
Ensure sources of support and
guidance are shared with all patients, recognising any difficulties and
referring where appropriate
Develop strong professional
relationships with patients, relatives, carers and other agencies with clear
communication, respect, collaboration and understanding regarding the care plan,
contingencies and risk assessments.
Able to communicate sensitive and
complex information, maintaining confidentiality and overcoming barriers to
communication that may arise.
Liaise with medical and
multidisciplinary team members to ensure timely delivery of prescribed care
acting as the key worker.
Managing self and others
Work within the NMC Code
To mentor junior staff ensuring that
they are supported and continually developed.
To develop the nursing services
offered both for the practice and through SHS.
To support clinical Supervision
within the practice.
To work with the practice and Lead
Nurse in the development of clinical skill mix Promote SHS values and acts as a
role model.
To Implement the SHS Nursing Strategy
as defined by the Head of Nursing & Quality and the Lead Nurses forum
To ensure a high level of patient
involvement and satisfaction with the service, including linking in with the
practice PPG.
Delivering a quality service
Produce accurate, contemporaneous and
complete records of patient consultation, consistent with legislation, policies
and procedures
Prioritise, organise and manage own
workload in a manner that maintains and promotes quality
Deliver care according to NSF, NICE
guidelines and evidence-based care
Assess effectiveness of care delivery
through self and peer review, benchmarking and formal appraisal.
Initiate and participate in the
maintenance of quality governance systems and processes across the organisation
and its activities
Utilise the 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 and wider organisation acting as the specialist.
Be involved in the review of and
identify learning from patient complaints, clinical incidents and near-miss
events
Assess the impact of policy
implementation on care delivery within own remit
Personal development
Take responsibility for own learning
and performance including participating in clinical supervision and acting as a
positive role model
Critically evaluate and review
innovations and developments that are relevant to the area of work
Enlist support and influence
stakeholders and decision-makers in order to bring about new developments in
the provision of services
Take a lead role in planning and
implementing changes within the area of care and responsibility
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
Act as a role model and promote the
role internally and to external stakeholders.
Team working
Understand own role and scope and
identify how this may develop over time
Work as an effective and responsible
team member, supporting others and exploring the mechanisms to develop new ways
of working
Delegate clearly and appropriately,
adopting the principles of safe practice and assessment of competence
Create clear referral mechanisms to
meet patient need
Prioritise own workload and ensure
effective time-management strategies are embedded within the culture of the
team
Work effectively with others to
clearly define values, direction and policies impacting upon care delivery
Discuss, highlight and work with the
team to create opportunities to improve patient care
Manage and lead on the delivery of
specifically identified services or projects as agreed with the practice
management team
Agree plans and outcomes by which to
measure success
Management of risk
Manage and assess risk within the
areas of responsibility, ensuring adequate measures are in place to protect
staff and patients
Monitor work areas and practices to
ensure they are safe and free from hazards and conform to health, safety and
security legislation, policies, procedures and guidelines
Ensure adherence to the Non-Medical
Prescribing policy or act within PGD compliance.
Apply infection-control measures
within the practice according to SHS and national guidelines
Interpret national strategies and
policies into local implementation strategies that are aligned to the values
and culture of general practice
Managing information
Use technology and appropriate
software as an aid to management in planning, implementation and monitoring of
care, presenting and communicating information
Review and process data using
accurate Read codes in order to ensure easy and accurate information retrieval
for monitoring and audit processes
Understand responsibility of self and
others to comply with Information governance legislation.
Manage, in conjunction with the QoF
team, the QoF targets.
Learning and development
Disseminate learning and information
gained to other team members in order to share good practice and inform others
about current and future developments (e.g. courses and conferences)
Assess own learning needs and
undertake learning as appropriate
Provide an educational role to
patients, carers, families and colleagues in an environment that facilitates
learning
Establish an evidence base for
practice, through benchmarking, audit, Quality Improvement and research
ensuring that outcomes are disseminated locally, regionally, and nationally as
appropriate.
Equality and diversity
Identify patterns of discrimination
and take action to overcome this and promote diversity and equality of
opportunity
Enable others to promote equality and
diversity in a non-discriminatory culture
Support people who need assistance in
exercising their rights
Monitor and evaluate adherence to
local chaperoning policies
Act as a role model in the observance
of equality and diversity good practice
Accept the rights of individuals to
choose their care providers, participate in care and refuses care. Assist
patients from marginalised groups to access quality care
NB: This list is
not exhaustive and may be added to or amended according to the needs of the
practice.
