Job summary
This role will play a key role working with our Frailty
Specialist Clinical Practitioner and the wider multi-disciplinary team,
delivering excellent, patient-facing care. You will visit frail, housebound
patients in their homes, returning to a GP practice for debriefing,
team-working and administration. You may also spend some time working within the practices providing
services for their diabetic patients and general patient cohort.
Frailty
is a condition affecting older people in which their bodys ability to cope
with certain events is
impaired and they are vulnerable to falls, disability and admissions. Housebound frail patients in particular can struggle to access
pro-active health care. Personalised care planning is aimed at improving their
health and wellbeing and preventing adverse outcomes.
This
post is part of the Additional Roles Reimbursement Scheme (ARRS) for PCNs.
With
support from the patients GP and other colleagues, you will work
with the FSP to undertake reviews, including taking/recording
clinical observations, the completion of local care planning,
appropriate elements of long-term condition reviews, evidenced based
intervention, advice and emotional support to the patient and where appropriate, their carer. You will work collaboratively
with the health and social care team to meet the needs of the patients,
supporting the delivery of appropriate care. You may be expected to undertake
similar work within the practices for a more general patient
cohort.
Main duties of the job
Primary Responsibilities
Work clinical sessions providing F2F appointments in the patients home and surgery and telephone follow up where appropriate
Be able to undertake and record clinical observations accurately
Be able to undertake other clinical assessment
Be aware of the importance of continence issue and pressure areas including a basic assessment of these
Meet complex needs of frail people through assessments and helping to develop a personalised advanced care plan using shared decision making
Utilise a range of evidence based interventions to promote health, wellbeing & self-management
Provide preventative health care and advice
Understand the needs of frail patients and be aware of local services which are available to them
Manage a cross-practice consolidated caseload of frail housebound patients, including helping to prioritise their reviews and plan the visiting schedule
Act on alerts and reminders during a consultation
Be able to undertake phlebotomy
Give vaccines as required under a PSD
Liaise with colleagues regarding onward treatment
Be confident in raising awareness of advanced care planning
Have excellent consultation skills to enable shared patient and practitioner decision-making
Participate in MDT team meetings
Recognise limitations and seek support where appropriate
Record clear IT based consultation notes
Collect data for audit purposes
About us
H&W
Health Ltd is a company providing services for Hitchin and Whitwell Primary
Care Network (HWPCN). HWPCN was the Hertfordshire and West Essex PCN of the
Year in 2024.
PCNs
build on existing primary care services and enable new and innovative
approaches to improve patient care and access to services. HWPCN covers
approximately 47,000 patients from four local GP surgeries. We are a dynamic
and forward-thinking PCN, with a team of ARRS including clinical pharmacists,
physiotherapists, social prescribing link workers, health & wellbeing
coaches and care coordinators, supported by an operations manager, a business
manager and a clinical director. We facilitate our PCN staff to integrate into
practice teams and pride ourselves on providing a friendly and supportive
working environment.
Hitchin
is a market town in Hertfordshire with excellent schools and transport links.
Job description
Job responsibilities
Primary Responsibilities
- Work clinical sessions providing face to face appointments in the patients home and surgery and telephone follow up where appropriate
- Be able to undertake and record clinical observations such as blood pressure, pulse and temperature accurately
- Be able to undertake other clinical assessments, including but not limited to: diabetic foot checks, Rockwood scoring, FRAT assessment
- Be aware of the importance of continence issue and pressure areas including a basic assessment of these
- Meet the multiple and often complex needs of frail people through assessment of health and wellbeing, helping to develop a personalised advanced care plan using shared decision making
- Utilise a range of effective evidence based interventions to promote health, wellbeing and self-management
- Provide appropriate preventative health care and advice
- Understand the needs of frail patients and be aware of local services which are available to support them
- Manage a cross-practice consolidated caseload of frail housebound patients, including helping to prioritise their reviews and plan the visiting schedule
- Act on alerts (e.g. QOF, local enhanced services etc.) and reminders during a consultation
- Be able to undertake phlebotomy
- Give immunisations as required under a PSD
- Liaise with other clinical colleagues regarding onward investigation, treatment and referral where appropriate
- Be confident and compassionate in raising awareness of advanced care planning
- Have excellent consultation skills to enable shared patient and practitioner decision-making
- Participate in multi-disciplinary team meetings
- Recognise your limitations and seek senior support where appropriate
- Record clear and contemporaneous IT based consultation notes to agreed standards
- Collect data for audit purposes
Secondary Responsibilities
In addition to the primary responsibilities, the Health Care Support Worker may be requested to:
- Participate in practice audits as requested by the audit lead
- Participate in local initiatives to enhance service delivery and patient care
- Participate in the review of significant and near-miss events applying a
- structured approach i.e. root cause analysis (RCA)
This list is not exhaustive and there may be on occasion, a requirement to carry out other tasks; this will be dependent upon factors such as workload, staffing levels and the needs of the business.
Generic Responsibilities
Confidentiality
- All staff are required to respect the confidentiality of all H&W Health, HWPCN and Practice business and the business of the staff, residents, patients and general public which they may learn in the execution of their duties.
Data Protection
- All staff are expected to adhere to the current laws regarding data protection.
Health and Safety
All staff are expected:
- To carry out the duties placed on employees by the Health and Safety at Work Act 1974, , Environmental Protection Act 1990, Environment Act 1995, Fire Precautions (workplace) Regulations 1999 and other statutory legislation.
- To take reasonable care for the Health and Safety of themselves and of other persons who may be affected by their acts or omissions at work.
- To co-operate with their employer as far as is necessary to meet the requirements of the legislation.
- Not to intentionally or recklessly interfere with or misuse anything provided in the interest of health, safety or welfare in the pursuance of any relevant statutory provision.
Equality and Diversity
- You must uphold the PCN commitment that all people will be valued regardless of their economic circumstances, disability, race, age, gender, sexual orientation, religion or belief, transgender status, pregnancy, maternity, partnership or marital status.
Risk Management
All staff are expected:
- To have a commitment to identifying and minimising risk, report all incidents and any risks which need to be assessed.
- To always comply with the Practices/PCNs/Companys Health and Safety policies. To follow agreed safe working practices and report any incidents or concerns to the practice manager, PCN director and senior clinic pharmacist.
Professional Registration
- All qualified/professional staff are required to keep professionally registered and updated in accordance with the requirements of the relevant Code of Practice and to follow guidance issued by their professional body.
Policies and Procedures
- The post holder is expected to comply with all relevant PCN policies, procedures and guidelines.
Quality & Continuous Improvement (CI)
- All staff are expected to strive for continuous improvement and to raise ideas and concerns with their line manager
Learning and Development
- All staff will be required to partake and complete a company induction and mandatory training, as well as participating in PCN training activities.
Collaborative Working
All staff are expected:
- To recognise the significance of collaborative working.
- To communicate in a manner which enables the sharing of information appropriately and professionally.
Professional Conduct
- Staff are required to dress appropriately for their role
Leave
- Staff are encouraged to use all of their annual leave entitlement,
Job description
Job responsibilities
Primary Responsibilities
- Work clinical sessions providing face to face appointments in the patients home and surgery and telephone follow up where appropriate
- Be able to undertake and record clinical observations such as blood pressure, pulse and temperature accurately
- Be able to undertake other clinical assessments, including but not limited to: diabetic foot checks, Rockwood scoring, FRAT assessment
- Be aware of the importance of continence issue and pressure areas including a basic assessment of these
- Meet the multiple and often complex needs of frail people through assessment of health and wellbeing, helping to develop a personalised advanced care plan using shared decision making
- Utilise a range of effective evidence based interventions to promote health, wellbeing and self-management
- Provide appropriate preventative health care and advice
- Understand the needs of frail patients and be aware of local services which are available to support them
- Manage a cross-practice consolidated caseload of frail housebound patients, including helping to prioritise their reviews and plan the visiting schedule
- Act on alerts (e.g. QOF, local enhanced services etc.) and reminders during a consultation
- Be able to undertake phlebotomy
- Give immunisations as required under a PSD
- Liaise with other clinical colleagues regarding onward investigation, treatment and referral where appropriate
- Be confident and compassionate in raising awareness of advanced care planning
- Have excellent consultation skills to enable shared patient and practitioner decision-making
- Participate in multi-disciplinary team meetings
- Recognise your limitations and seek senior support where appropriate
- Record clear and contemporaneous IT based consultation notes to agreed standards
- Collect data for audit purposes
Secondary Responsibilities
In addition to the primary responsibilities, the Health Care Support Worker may be requested to:
- Participate in practice audits as requested by the audit lead
- Participate in local initiatives to enhance service delivery and patient care
- Participate in the review of significant and near-miss events applying a
- structured approach i.e. root cause analysis (RCA)
This list is not exhaustive and there may be on occasion, a requirement to carry out other tasks; this will be dependent upon factors such as workload, staffing levels and the needs of the business.
Generic Responsibilities
Confidentiality
- All staff are required to respect the confidentiality of all H&W Health, HWPCN and Practice business and the business of the staff, residents, patients and general public which they may learn in the execution of their duties.
Data Protection
- All staff are expected to adhere to the current laws regarding data protection.
Health and Safety
All staff are expected:
- To carry out the duties placed on employees by the Health and Safety at Work Act 1974, , Environmental Protection Act 1990, Environment Act 1995, Fire Precautions (workplace) Regulations 1999 and other statutory legislation.
- To take reasonable care for the Health and Safety of themselves and of other persons who may be affected by their acts or omissions at work.
- To co-operate with their employer as far as is necessary to meet the requirements of the legislation.
- Not to intentionally or recklessly interfere with or misuse anything provided in the interest of health, safety or welfare in the pursuance of any relevant statutory provision.
Equality and Diversity
- You must uphold the PCN commitment that all people will be valued regardless of their economic circumstances, disability, race, age, gender, sexual orientation, religion or belief, transgender status, pregnancy, maternity, partnership or marital status.
Risk Management
All staff are expected:
- To have a commitment to identifying and minimising risk, report all incidents and any risks which need to be assessed.
- To always comply with the Practices/PCNs/Companys Health and Safety policies. To follow agreed safe working practices and report any incidents or concerns to the practice manager, PCN director and senior clinic pharmacist.
Professional Registration
- All qualified/professional staff are required to keep professionally registered and updated in accordance with the requirements of the relevant Code of Practice and to follow guidance issued by their professional body.
Policies and Procedures
- The post holder is expected to comply with all relevant PCN policies, procedures and guidelines.
Quality & Continuous Improvement (CI)
- All staff are expected to strive for continuous improvement and to raise ideas and concerns with their line manager
Learning and Development
- All staff will be required to partake and complete a company induction and mandatory training, as well as participating in PCN training activities.
Collaborative Working
All staff are expected:
- To recognise the significance of collaborative working.
- To communicate in a manner which enables the sharing of information appropriately and professionally.
Professional Conduct
- Staff are required to dress appropriately for their role
Leave
- Staff are encouraged to use all of their annual leave entitlement,
Person Specification
Qualifications
Essential
- Care Certificate, Clinical Healthcare Support Qualification or equivalent
- Recent employment as a Health Care Assistant or Health Care Support worker
Personal Qualities
Essential
- Polite and confident
- Flexible and cooperative
- Motivated, forward thinker
- Problem solver with the ability to process information accurately and effectively, interpreting data as required
- High levels of integrity and loyalty
- Sensitive and empathetic in distressing situations
- Ability to work under pressure / in stressful situations
- Effectively able to communicate and understand the needs of the patient
- Commitment to ongoing professional development
Skills
Essential
- Excellent communication skills (written and oral)
- Strong IT skills
- Clear, polite telephone manner
- Competent in the use of Office and Outlook
- SystmOne user skills
- Effective time management (Planning & Organising)
- Ability to work as a team member and autonomously
- Excellent interpersonal skills
- Problem solving & analytical skills
- Ability to follow clinical policy and procedure
- Experience with audit and able to lead audit programmes
- Experience with clinical risk management
Experience
Essential
- Experience of working in a primary care environment
- Experience of continued professional development
- Experience of providing hands-on patient care
Desirable
- Experience of working in multi-disciplinary teams
- Experience of working in palliative care
Clinical Knowledge & Skills
Essential
- Excellent level of clinical knowledge and skills including basic observations such as height, weight, temperature, blood pressure, pulse
- Excellent communication skills (written and oral)
- Strong IT skills
- Clear, polite telephone manner
- Competent in the use of Office and Outlook
- SystmOne user skills
- Effective time management (Planning & Organising)
- Ability to work as a team member and autonomously
- Excellent interpersonal skills
- Problem solving & analytical skills
- Ability to follow clinical policy and procedure
- Experience with audit and able to lead audit programmes
- Experience with clinical risk management
- Effectively able to communicate and understand the needs of the patient
- Commitment to ongoing professional development
Desirable
- Ability to perform diabetic foot check
- Competent to perform phlebotomy
- Competent to perform ear syringing
Person Specification
Qualifications
Essential
- Care Certificate, Clinical Healthcare Support Qualification or equivalent
- Recent employment as a Health Care Assistant or Health Care Support worker
Personal Qualities
Essential
- Polite and confident
- Flexible and cooperative
- Motivated, forward thinker
- Problem solver with the ability to process information accurately and effectively, interpreting data as required
- High levels of integrity and loyalty
- Sensitive and empathetic in distressing situations
- Ability to work under pressure / in stressful situations
- Effectively able to communicate and understand the needs of the patient
- Commitment to ongoing professional development
Skills
Essential
- Excellent communication skills (written and oral)
- Strong IT skills
- Clear, polite telephone manner
- Competent in the use of Office and Outlook
- SystmOne user skills
- Effective time management (Planning & Organising)
- Ability to work as a team member and autonomously
- Excellent interpersonal skills
- Problem solving & analytical skills
- Ability to follow clinical policy and procedure
- Experience with audit and able to lead audit programmes
- Experience with clinical risk management
Experience
Essential
- Experience of working in a primary care environment
- Experience of continued professional development
- Experience of providing hands-on patient care
Desirable
- Experience of working in multi-disciplinary teams
- Experience of working in palliative care
Clinical Knowledge & Skills
Essential
- Excellent level of clinical knowledge and skills including basic observations such as height, weight, temperature, blood pressure, pulse
- Excellent communication skills (written and oral)
- Strong IT skills
- Clear, polite telephone manner
- Competent in the use of Office and Outlook
- SystmOne user skills
- Effective time management (Planning & Organising)
- Ability to work as a team member and autonomously
- Excellent interpersonal skills
- Problem solving & analytical skills
- Ability to follow clinical policy and procedure
- Experience with audit and able to lead audit programmes
- Experience with clinical risk management
- Effectively able to communicate and understand the needs of the patient
- Commitment to ongoing professional development
Desirable
- Ability to perform diabetic foot check
- Competent to perform phlebotomy
- Competent to perform ear syringing
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.
