PCN Mental Health Enhanced Practice Nurse in Colne

About Us

The Confederation, Hillingdon CIC works with General Practice and other healthcare providers to deliver its vision for "Hillingdon to deliver the best primary care outcomes for patients in the whole of London". We are a not-for-profit community interest company. The Confederation works to develop and support individual GP practices, PCNs and Neighbourhoods and their changing needs. We deliver excellent clinical services ourselves both at scale and complementary to General Practice. We are the provider representative voice for local General Practice into the wider NHS and other Partners. We are 'of the NHS' but independent, innovative and transformational.

The Confederation determines to develop as an attractive place to work, providing rewarding roles and opportunities to grow in order to attract and retain great staff that in turn delivers our vision.

Location

The role is based in Colne Union PCN in Yiewsley / West Drayton.

The PCN Covers the Following Practices

• High Street Practice
• Oakland Medical Centre
• Otterfield Medical Centre
• The Green Medical Centre
• Yiewsley Family Practice

Job Summary

The post holder will be an experienced registered nurse working at enhanced practice level across the Primary Care Network, with a specialist focus on mental health and learning disabilities. Working autonomously within an agreed scope of practice, the post holder will provide high-quality, person-centred care for adults with severe mental illness, common mental health problems, learning disabilities, autism, neurodevelopmental needs and associated physical health inequalities. They will use specialist knowledge, enhanced assessment skills and evidence-based clinical decision‑making to assess need, formulate and review personalised care plans, monitor treatment, support recovery and independence, and make timely referrals or escalation where required.

The post holder will work closely with general practice, community mental health and learning‑disability services, social care, pharmacy and voluntary‑sector partners. They will contribute to annual physical health checks, proactive review, medicines monitoring, prevention, early identification of deterioration, crisis planning, safeguarding and reduction of health inequalities. They will provide clinical leadership, support the development of colleagues and lead or contribute to quality improvement, audit and service development. The post holder will recognise the limits of their competence and seek appropriate advice or refer to an advanced practitioner, GP, psychiatrist, community mental health team, learning‑disability service or other clinician when needed.

Primary Responsibilities

Clinical Practice

• Work autonomously and accountably within the NMC Code, local policies, agreed clinical pathways and the limits of the role and individual competence.
• Undertake comprehensive, holistic assessments of mental health, learning‑disability needs, physical health, cognition, communication, social circumstances, functioning, strengths, risks and protective factors.
• Use enhanced mental health and physical assessment skills to identify deterioration, relapse, unmet need, adverse treatment effects, diagnostic shadowing and conditions requiring urgent medical or specialist review.
• Develop, implement and evaluate personalised care and support plans in partnership with patients, families, carers, advocates and the multidisciplinary team, promoting recovery, independence and quality of life.
• Provide enhanced‑level management for one or more defined specialist areas, such as severe mental illness, depression and anxiety, learning disabilities, autism, dementia, neurodevelopmental needs or another locally agreed priority.
• Complete and coordinate physical health reviews for people with severe mental illness, including relevant observations, lifestyle review, cardiovascular and metabolic risk assessment, blood tests, screening, medicines monitoring and follow‑up within competence.
• Undertake or coordinate annual health checks and health action plans for people with learning disabilities, ensuring reasonable adjustments, accessible communication and timely action on identified physical and mental health needs.
• Review treatment effectiveness and, where qualified as an independent prescriber, prescribe, deprescribe and review medicines in accordance with evidence, national guidance, local formularies and professional accountability.
• Monitor the safety and effectiveness of psychotropic and other medicines, support adherence, identify adverse effects and interactions, and arrange appropriate investigation, referral or specialist review.
• Use psychologically informed and evidence-based approaches to support self‑management, emotional wellbeing, relapse prevention, behaviour change, coping strategies and recovery goals within scope of practice.
• Assess risk relating to self‑harm, suicide, self‑neglect, exploitation, abuse, violence, vulnerability, deterioration or carer breakdown, and develop proportionate safety, crisis and escalation plans.
• Recognise mental health crisis, acute behavioural change, delirium, severe distress, safeguarding concerns and urgent or emergency presentations; initiate immediate care and escalat or refer without delay.
• Assess decision‑making capacity relevant to the care or treatment being considered, support communication and involvement, and follow legal and organisational requirements for consent and best‑interest decision‑making.
• Undertake home, care home, supported‑living or community visits when required by the service and when clinically appropriate.
• Maintain accurate, contemporaneous and complete clinical records, including clear documentation of assessment, formulation, clinical reasoning, risk, capacity, consent, plans, advice, escalation and outcomes.
• Population Health and PCN Service Delivery:
• Use practice and PCN data to identify people with severe mental illness, learning disabilities, autism or other mental health needs who are at risk, overdue review, experiencing poor access or likely to benefit from proactive intervention.
• Support achievement of relevant Quality and Outcomes Framework, PCN, local enhanced service and contractual priorities while maintaining person‑centred and clinically appropriate care.
• Improve uptake and quality of severe mental illness physical health checks, learning‑disability annual health checks, screening, immunisation and other prevention activity through proactive recall, follow‑up and reasonable adjustments.
• Identify and address physical health inequalities, premature mortality risks, barriers to access and unmet health needs affecting people with mental illness or learning disabilities.
• Support proactive care for people with complex mental, physical and social needs through risk stratification, anticipatory care, personalised care planning and multidisciplinary review.
• Contribute to enhanced access and other PCN‑wide clinical services, including delivery across different member practices and community settings where required.
• Work with integrated neighbourhood teams and partner organisations to improve continuity, care coordination, crisis prevention and outcomes for people who may otherwise experience fragmented care.
• Evaluate the impact of clinical interventions and service changes using agreed outcome measures, patient and carer feedback, inequalities data and audit findings.

Communication

• Use sensitive, inclusive and effective communication to support informed choice, consent and shared decision‑making.
• Adapt communication to meet language, sensory, cognitive, cultural and health‑literacy needs, using interpreting or accessible information services where appropriate.
• Communicate complex or sensitive information to patients and carers with compassion, including discussions about deterioration, risk, treatment burden and changes to care.
• Provide clear advice on self‑care, symptom monitoring, when to seek help and how to access appropriate services.
• Act as an advocate for patients and carers, supporting their involvement in care and respecting their right to accept or refuse treatment.
• Maintain effective communication with colleagues across the PCN, practices, community services, hospitals, mental health services, social care and the voluntary sector.
• Address concerns and conflict professionally, escalating unresolved risks through the appropriate governance route.

Delivering a Quality Service

• Recognise and work within own competence and professional code of conduct as regulated by the NMC
• 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 evaluation
• 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
• Use a structured framework (e.g. root‑cause analysis) to manage, review and identify learning from patient complaints, clinical incidents and near‑miss events
• Assess the impact of policy implementation on care delivery
• Working with the practice management monitor and develop the performance of the GPN team in accordance with local policies
• Contribute to the appraisal of the performance of the team, providing feedback as appropriate
• Understand and apply legal issues that support the identification of vulnerable and abused children and adults at risk and be aware of statutory child/vulnerable patients health procedures and local guidance
• Working with practice management to ensure the whole team have skills and knowledge regarding domestic violence, vulnerable adults, substance abuse and addictive behaviour. Provide guidance and support to ensure appropriate referral if required

Leadership – Personal and People Development

• Act as a clinical leader in the delivery of practice nursing services ensuring that the needs of the patient are a priority
• Take responsibility for own learning and performance including participating in clinical supervision and acting as a positive role model
• Support staff development in order to maximise potential
• Actively promote the workplace as a learning environment, encouraging everyone to learn from each other and from external good practice
• Encourage others to make realistic self‑assessment of their application of knowledge and skills