Practice Nurse / Care Home Link Nurse

Main duties of the job

The post holder will act as the key clinical link between GP practices and aligned care and nursing homes, delivering comprehensive nursing assessments, personalised care planning, and regular reviews for residents. The role involves leading and coordinating multidisciplinary team meetings, identifying and managing early signs of deterioration to prevent avoidable hospital admissions, and responding appropriately to urgent and emergency situations. The nurse will provide clinical advice, education and support to care home staff, residents and families, deliver a range of clinical interventions including long‑term condition management, wound care, and immunisations, and promote prevention, health education, and vaccination programmes. Working closely with GPs, primary care teams, and external services, the post holder will ensure coordinated, high‑quality, patient‑centred care while contributing to service development, audits, and quality improvement initiatives.

Job responsibilities

• Assess, plan, implement and evaluate programmes of care to improve health and wellbeing and meet the healthcare needs of individuals and groups.
• Prioritise health problems and intervene appropriately to assist the patient in complex, urgent or emergency situations, including initiation of effective emergency care.
• Enable patients, families and carers to develop their knowledge and understanding about their health and well‑being and be as self‑managing as possible.
• Offer health promotion programmes by providing a holistic assessment, which may include: BP checks, height, weight, BMI, urinalysis and smoking status.
• Breast health awareness, Cervical screening, New patient checks.
• Well‑man/woman checks.
• Advice for healthy eating, exercise, alcohol consumption and smoking.
• Perform routine nursing tasks such as: Venepuncture, Recording ECG, Chaperoning and assisting patients.
• Provide a holistic approach to wound management and implement wound care in line with current evidence‑based guidelines.
• Offer advice about childhood and adult vaccinations and administer vaccines according to current guidelines and legislation.
• Advise and administer vaccinations for patients travelling abroad.
• Assist in the provision of treatment plans to meet family planning needs.
• Administer and monitor medication consistent with protocols, standards, and legislation.
• Assist in the provision of minor surgery and other surgical procedures that are carried out within Haxby Group.
• Assist in the provision of nursing care within the context of primary care for patients with mental health problems.
• Delegate aspects of care as appropriate.
• Monitor and manage maintenance of stock and equipment.

Care Home Link Nurse Responsibilities

• Act as a point of contact for aligned care homes building effective working relationships with care home staff, residents and families.
• Attend multidisciplinary team (MDT) reviews.
• Develop and update personalised care and support plans.
• Conduct comprehensive nursing assessments, including for long‑term conditions and frailty.
• Identify, diagnose, and manage treatment plans for at‑risk patients.
• Support patients and carers with treatment adherence and health promotion.
• Respond to urgent or emergency situations and initiate appropriate care.
• Identify and manage early signs of health deterioration.
• Implement and support vaccination and immunisation programmes.
• Assess and refer patients with mental health needs as per guidelines.
• Communicate sensitively and effectively with patients, carers, and colleagues.
• Work alongside GPs and primary care professionals to manage caseloads.
• Actively contribute to the primary care team, including service improvement and research.
• Contribute to prevention and early intervention initiatives.
• Undertake clinical duties as directed such as wound care, immunisations, chronic disease management, and phlebotomy where required.
• Deliver proactive care, including health promotion and preventative healthcare for residents.
• Liaise with and refer to the appropriate services for ongoing patient care management.
• Contribute to audits and quality improvement projects aimed at enhancing care for care home residents.

Other responsibilities

• Recognise and work within own competence and in accordance with the professional code of conduct of the Nursing and Midwifery Council.
• Maintain accurate and complete documentation and records utilising IT as appropriate and in accordance with Haxby Group protocol.
• Use own judgement, resourcefulness, and common sense.
• Follow agreed protocols, referring to experienced nurses or GPs as appropriate.
• Follow local and national Infection Control guidelines.
• Demonstrate awareness of statutory and local child protection procedures, including systems of referral.
• Contribute to achievement of the highest possible quality standards such as the QOF and other agreed Key Performance Indicator targets.
• Attend in‑house governance, educational and staff meetings as appropriate.
• Assist with the training of other staff members and with the education of doctors, nurses and other health professionals in training as appropriate.
• Facilitate change.
• Demonstrate pro‑active engagement with the practice population and wider community to promote healthy living and encourage uptake of services. This may include visits to local schools, community centres and other groups as necessary.
• Undertake additional tasks as required within your general role as nurse.

Person Specification

• Ability to work independently.
• Ability to work as team player.
• Initiative and drive.
• Pleasant and articulate.
• Able to work under pressure.
• Self‑motivated and positive.
• Empathetic, honest, caring.
• Adaptable and forward looking.
• Enthusiastic and energetic.
• Diplomatic and considered.
• Hard working, willing and flexible.
• Observance of strict confidentiality.
• Ability to use own judgement, resourcefulness and common sense.

Physical Requirements

• Able to undertake the requirements of the post.
• Reliable.
• Flexible.
• Excellent attendance record.

Attributes and Competencies

• Gets on well with people at all levels.
• Ability to listen and empathise.
• Ability to organise and prioritise workload.
• Demonstrable commitment to professional development.
• Practice nursing or other community nursing experience.
• Evidence of working autonomously, with some support and supervision.
• Proven ability to evaluate the safety and effectiveness of own clinical practice.
• Experience of Microsoft Office applications.
• Experience of GP Clinical IT systems.
• Experience of audit.

Knowledge and Skills

• Registered Nurse (NMC).
• Aware of accountability of own role and that required of a Practice Nurse.
• Good communication (oral and written) and interpersonal skills.
• Recognised cervical screening qualification.
• Clinical skills - vaccination, wound care, ear care, venepuncture, recording ECGs, spirometry.
• Knowledge of health promotion strategies.
• Change management skills and ability to support patients to change lifestyle.

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.