Long-Term Conditions Registered Nurse

Manage an agreed caseload and waiting list of adults with

single or multiple long-term conditions, prioritising those at risk of

deterioration, avoidable hospital admission or health inequality.

Undertake comprehensive, holistic assessments in patients

homes and care homes, considering physical and mental health, frailty,

function, cognition, medicines, nutrition, falls risk, social circumstances,

carer needs and safeguarding.

Complete structured long-term condition reviews within

competence, including diabetes, cardiovascular disease, hypertension,

respiratory disease and frailty, in line with NICE guidance and local pathways.

Work collaboratively with patients, carers and professionals

to develop, implement and review personalised care and support plans, including

agreed goals, self-management support, escalation arrangements and advance care

planning where appropriate. Recognise deterioration and red flags, provide

immediate care within scope of practice and escalate promptly to the GP,

emergency services or relevant urgent care service.

Undertake and interpret clinical observations and

appropriate point-of-care or diagnostic tests. Support medicines optimisation,

immunisation, health promotion, prevention and self-management, where trained

and authorised.

Make timely referrals, coordinate care across health, social

care and voluntary services, and ensure patients and carers understand the

plan, who to contact and when to seek further help.

Manage an agreed waiting list of adults with single or

multiple long-term conditions, prioritising people at risk of deterioration,

avoidable admission or health inequality.

Undertake comprehensive holistic assessments in patients

homes and care homes, including physical health, mental wellbeing, frailty,

function, cognition, medicines, nutrition, falls risk, social circumstances,

carer needs and safeguarding.

Complete structured long-term condition reviews within

competence, including conditions such as diabetes, cardiovascular disease,

hypertension, respiratory disease and frailty, using current NICE guidance and

local pathways.

Develop, implement and evaluate personalised care and

support plans with patients, carers and relevant professionals, including

agreed goals, self-management support, escalation arrangements and advance care

planning where appropriate.

Identify early deterioration or red flags, initiate

immediate care within scope of practice and escalate promptly to the

responsible GP, emergency services, urgent community response or other

appropriate service.

Undertake and interpret relevant clinical observations and

point-of-care or diagnostic tests within competence and service protocols.

Support medicines optimisation through reconciliation,

adherence review, side-effect monitoring and timely referral to a GP, clinical

pharmacist or independent prescriber.

Provide immunisation, health promotion, prevention and

supported self-management interventions where trained, authorised and

clinically appropriate.

Make timely referrals and coordinate care across primary

care, community nursing, specialist teams, pharmacy, therapy, mental health,

adult social care, care homes, voluntary services, urgent community response

and virtual wards.

Ensure that the patient and carer understand the care plan,

who to contact and when to seek further help.

Work as an integral member of the Belper PCN Home Visiting

Service, collaborating with GPs, advanced clinical practitioners, nurses,

nursing associates, pharmacists, care coordinators, social prescribers and

other professionals.

Participate in clinical huddles, multidisciplinary meetings,

care home discussions and case reviews, contributing nursing expertise and

coordinated plans.

Liaise with the patients registered practice and named

clinician to maintain continuity, clear accountability and timely follow-up.

Promote a no wrong door approach by helping patients and

professionals navigate the most appropriate local support.

Build effective relationships with neighbourhood partners

and contribute to service integration, pathway development and joint learning.

Use PCN data, clinical registers and risk-stratification

processes to help identify people who would benefit from proactive

intervention, in accordance with information governance requirements.

Address modifiable risk factors, support vaccination and

screening uptake, encourage rehabilitation and self-management, and signpost to

local community resources.

Recognise barriers associated with deprivation, rurality,

disability, cognition, language, caring responsibilities or digital exclusion;

make reasonable adjustments and advocate for equitable access.

Use approved digital systems, remote monitoring and

communication tools to improve continuity and efficiency while retaining

face-to-face care where clinically required or preferred.

Record accurate, contemporaneous and appropriately coded

information in the shared electronic patient record and support agreed outcome

reporting.

Practise within the Nursing and Midwifery Council Code,

professional competence, indemnity arrangements, legislation, NICE guidance and

Belper PCN policies.

Maintain professional registration, mandatory training and

an evidence-based portfolio; participate in appraisal, clinical supervision and

continuing professional development.

Obtain valid consent, assess capacity where relevant and

uphold confidentiality, dignity, equality and patient choice.

Follow safeguarding, infection prevention and control,

medicines management, lone-working, chaperone, incident reporting and

information governance procedures.

Recognise the limits of competence, seek advice and escalate

clinical uncertainty or risk to the designated senior clinician.

Contribute to audit, quality improvement, patient-safety

reviews, complaints learning, patient experience and service evaluation.

Use equipment safely, maintain stock and report faults,

risks or incidents promptly.

Communicate complex or sensitive information clearly and

compassionately, adapting to individual communication needs and using

interpreters or accessible formats when required.

Provide education and coaching to patients, carers,

care-home staff and colleagues on long-term condition management, prevention

and recognition of deterioration.

Support induction, peer learning and development of less

experienced staff or students where appropriate.

Act as a positive role model for person-centred, integrated

and improvement-focused practice.

Manage time and workload effectively, balancing planned

proactive care with changing clinical priorities.

Regular travel across the Belper PCN area and work in

patients homes, care homes and other community settings.

Ability to work independently while maintaining reliable

communication and access to clinical support.

Exposure to unpredictable environments, distressing

circumstances, infection risks and manual-handling considerations; all risks

must be managed through policy and dynamic risk assessment.

Flexibility to work within the service operating model,

which may include extended hours subject to contract.

Able to meet the travel requirements of the role; reasonable

adjustments will be considered.

Appointment is subject to satisfactory employment checks,

occupational health clearance and the appropriate Enhanced DBS check.

Patients, families and unpaid carers; Belper PCN practices;

GPs and the Home Visiting Service team; community nursing and specialist

long-term condition teams; urgent community response and virtual wards;

pharmacists and pharmacy technicians; therapists; mental health services; adult

social care; care homes; voluntary and community organisations; ambulance, NHS

111, out-of-hours and secondary care services.

Belper PCN consists of a collaboration of 4 local GP

practices working both together and with the broader health, social care,

housing and voluntary organisations to improve the health and wellbeing of our

local people within our neighbourhood. Our team cover urgent, planned, and

anticipatory care for our patients, working with a complete integration of

local services.

Belper PCN has adopted new initiatives to recruit

varied skills into the PCN team. With

the aim of offering community and clinical services to patients giving a more

holistic approach to health care and the opportunity to access a wider

selection of health professionals.

Qualifications

Experience

Knowledge and Skills