Community Nurse in Southampton

We are looking for an experienced community or practice nurse to join our already established Home Visiting and Care Home team. The nurse will provide home visits for housebound patients and care home residents within the PCN. These visits will include completing patients' annual reviews for long-term conditions (such as Diabetes), frailty assessments, and advanced care plans (including DNACPR status) to support both the practices QOF (Quality and Outcomes Framework) and the PCN Proactive Care contracts.

The post holder will be required to provide visits for patients in their own home who require updated observations and general reviews and assessments. The practitioner will also need to visit patients living in care homes. The clinician will be responsible for prioritising workload and will be required to take a comprehensive history and devise a comprehensive patient-focused plan. This could include liaison with the GP, secondary care, and community colleagues to support coordination of patient care.

As part of the proactive care service delivery, the post holder will be required to complete comprehensive frailty assessments and care plans. They can also take part in end-of-life care planning and medication optimisation dependent on experience. They will work closely with a wider MDT to identify patients who require input from other services or agencies.

Main duties of the job:

• Uses expert knowledge and clinical skills to deliver holistic care to housebound patients and care home residents registered with Southampton West PCN.
• Support the ongoing management of long-term conditions for patients in the PCN.
• Create care plans and frailty assessments for patients using specific templates required under the proactive care contract.
• Refers patients, as appropriate, to other members of the multidisciplinary team, secondary care, and to other statutory and voluntary organisations.
• Works within professional guidelines and codes of conduct.
• Works within all relevant policies and procedural guidelines e.g. infection control, chaperoning, risk management.
• Communicates information well and sensitively to patients and carers having due regard to confidentiality.
• Contributes toward targets under the primary Care Network Enhanced service and the Quality and Outcomes Framework.
• Undertakes and completes quality improvement projects where necessary.
• Accurately records clinical consultations on practice clinical systems ensuring the correct use of SNOMED codes and clinical templates.
• Understands and implements safeguarding protocols and understands how and who to refer and escalate to when required.
• Develops meaningful positive working relationships with local frailty teams and Multi Disciplinary Team.
• Helps to deliver vaccination programmes for our housebound populations and care home residents.

Person Specification:

Knowledge and Skills

• Communication and consultation skills.
• Practising holistically.
• Data gathering and interpretation.
• Making a diagnosis or decision.
• Managing medical complexity.
• Working in a team.
• Continuous professional development.
• Maintaining an ethical approach.
• Fitness to practise.
• Clinical examination and procedural skills.
• Learning and development.
• PCN Core values.
• Awareness of the legal and ethical issues of the role.
• Ability to work effectively in a multidisciplinary team as a key player.
• Adult safeguarding level 3.

Experience

• Essential: Own transport and driving license, in order to be able to travel regularly between sites around West Southampton.
• Desirable: Previous Care Home Primary Care experience; Background in community nursing.

Qualifications

• Essential: Nursing qualification; Current NMC Registration; Membership of a professional body; UK Driving license.

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.