Clinical Care Home Nurse

• Working with the Lead Care Home Nurse and Care-Co-ordinator, you would participate in the weekly care home rounds, undertake full holistic reviews, plan programmes of care including referring to other services.
• Reviewing residents care needs on admission to the care home and following hospital discharges.
• A significant part of the role is supporting residents and their families with advanced planning and the ReSpect process.

• RGN registered with NMC
• Post registration experience of managing frailty
• Experience of working across health and social care
• Sole use of a vehicle to get to multiple care homes and GP surgeries

• The post holder is responsible for ensuring that the residents and care home managers in within the PCN locality receive assistance in accessing health care interventions by signposting to the most appropriate person to provide care
• The post holder is responsible for consulting and collaborating with other Health Care professionals and specialists across both primary, secondary, social care and the voluntary care sectors
• To take a significant role in the assessment and treatment of patients in care homes with complex illnesses.
• To confidently consult with patients/families/carers to determine the needs of individuals and develop and review care plans to support care.
• To confidently make autonomous decisions following assessments and ensuring that information is collaboratively communicated back to the Senior PCN Clinical Care Home Nurse / GP colleagues in a timely and professional manner
• To lead in the weekly home rounds and have the ability and knowledge to make decisions regards appropriateness of onward referrals and hold others to account for their delivery of actions.
• Make recommendations regarding patient management in accordance with Local and National guidelines within the management of the older population.
• To develop the evidence, base for health needs led service planning, delivery and commissioning.
• To develop / prescribe specialised programmes of care / care packages for all patients referred to the team, monitor and evaluate effectiveness of implementation. This includes developing training programmes and providing guidance to all clinicians both professional and non-professional across the health community.
• Demonstrate a good understanding of clinical governance and risk management and apply to work effectively alerting any risks and benefits when developing services and practice in new areas.
• To participate in research and service development.
• Keep abreast of new developments in treatment and technology.
• Promote the philosophy of patient centred care and with care homes facilitate a forum for patients' carers to reflect and feedback issues and concerns.
• Communications across the MDT is a critical element for this role. Information will be shared across providers, and the post holder will support the voice of the residents and care homes as equal members of the MDT.
• With colleagues in the team and utilising and interpreting data, to support service improvement for care homes and primary care, as well as understanding the demands on urgent and emergency services to reduce avoidable activity where possible. Data and local intelligence will be utilised to develop and influence new ways of working to improve patient care, the resilience of primary care and system partners.
• The post holder will be supported by the Senior PCN Clinical Care Home Nurse, named care home GPs and the PCN GP clinical lead, and accountable to the PCN clinical director.
• The post holder will promote new ways of working promoting the use of digital technology, such as remote consultations, MS Teams MDTs, care home WhatsApp group and check ins.
• The post holder will be required to work with team colleagues to evidence the impacts of the team and provide data monitoring to further shape the role and delivery of the Care Home DES and LES within the PCN

• Primary Integrated Community Services Ltd Specialist Teams
• PCN Lead Care Home GP & Clinical Directors
• Care Homeowners, managers and staff
• GPs CCG and PCNs
• Community Geriatrician
• Secondary Care Consultants
• Community Matrons
• Community Therapy & Nursing Services
• Locality District & Social Services Departments
• Hospital Clinical Specialists
• Voluntary Sector
• CQC

• To be responsible for maintaining own competency to practice through Continuing Professional Development activities and to participate in the review and appraisal process.
• To always adhere to the individual Professional code of conduct and practice.
• To reflect on own practice individually and/or through regular clinical supervision.
• To participate in any relevant training/course/conferences to maintain own professional development.
• To maintain, develop and disseminate specialist knowledge of evidence-based practice.
• To critically evaluate own work using evidence-based projects, audits and outcome measures.
• To work autonomously as a Clinical Care Home nurse within professional and PICS guidelines, policies and procedures.

• Demonstrate good communication skills in providing advice, empowerment, facilitation, influence, motivation and counselling.
• Manage complex communication issues that may arise between differing health and social care professionals.
• Demonstrate an understanding of the need to involve patients and carers in decision making, offering them informed choices, respecting their views.
• Demonstrate the ability to recognise barriers to understanding that can be encountered with elderly frail patients, those without English as their first language, patients with disabilities and those with mental health difficulties such as dementia, anxiety, clinical depression or personality disorders.
• Seek out different styles and methods of communicating to assist longer term needs and aims.
• The nature of some communication can be unpredictable and can be of an urgent high priority nature: this can therefore be responsible for impacting into time allocated towards other necessary tasks.
• As a senior skilled clinician, manage difficult and challenging conversations, providing clarity and information to seek a mutually agreeable position between parties.

• This post demands a range of developed skills from a wide and variant background, experience and a knowledge base underpinned with a proven track record and/or an academically scrutinised knowledge base.
• Proven Professional Development, a profile that post registration experience and knowledge relating to the role
• To have the ability to contribute to complex care co-ordination, proactively manage complex long-term conditions.
• Support self-care, management enabling independence through concordance and using good consultation skills.
• Dealing with patients who have cognitive impairment and understand mental well-being.
• Dealing with care home staff where English is not the first language to promote education and training.
• Offer good consultation skills and develop specialist knowledge within the older persons setting and generalist knowledge to undertake comprehensive assessment of health and psychosocial care needs of patients with complex disease, including holistic assessment, gathering and interpreting information, performing tests and analysing results.
• Using clinical outcomes for patients by enabling them to function independently by increasing their choice to remain in their own care home setting and reduce the need for inappropriate hospital admissions/readmission.
• Work closely with the primary care clinical team to facilitate the understanding and concordance of medicines with patients and carers.
• Analytical judgement underpinned with specialist knowledge and experience is used to develop evidenced based holistic personal care plan with patients, carers, relatives and health care professionals based on a full assessment of medical, nursing, and social care needs.
• Work collaboratively with colleagues using databases to actively seek patients who will benefit from clinical cases management techniques to avoid unplanned hospital admissions and reduce the length of hospital admissions.

• NHS Pension 2015 Scheme (subject to eligibility)
• Alternative government-based scheme (subject to eligibility)
• Competitive leave entitlement that includes maternity, paternity and adoption leave, study leave allowance, and sickness provisions
• Access to education and training opportunities, depending on your role (CPPE Pharmacy, NHS England Roadmap for First Contact Practitioners, apprenticeship schemes, support professional development)
• Working in a multi-disciplinary team with support from a wide variety of professionals
• A flexible approach to a work-life balance
• Cycle to work scheme (subject to eligibility)
• Access to Blue Light Card scheme
• All staff events and conferences
• Staff engagement (Wellbeing Group, EDI Network, Staff Focus group)
• Free parking across many sites
• Personalised induction into the company and job role

Essential

• Please provide detailed information of how you feel that your experience is suitable for this role; please provide examples to support your application referring to the job description and person specification for guidance.

Essential

• Please provide detailed information of how you feel that your knowledge and skills are suitable for this role; please provide examples to support your application referring to the job description and person specification for guidance.

Essential

• Please provide detailed information of how you feel that your knowledge and skills are suitable for this role; please provide examples to support your application referring to the job description and person specification for guidance.