Proactive Care Nurse

North Kerrier is embarking on a transformational change journey to become North Kerrier Neighbourhood Health. We are located in the West of Cornwall, covering the area of Camborne, Pool, Redruth and Illogan.

Would you like to be part of an inclusive, supportive, and innovative team, that is co-located and where it is essential to enjoy daily coffee with your colleagues? Good beans provided! If the answer is yes, then you could be the missing part of our jigsaw. If you think you would be interested in joining our team then read on.

This is a new role and will be part of a North Kerrier Neighbourhood Health Proactive Care team (Carne to Coast, Godolphin, Harris Memorial, Leatside Health Centre and Veor Surgery, GP Practices).

Main duties of the job

To lead proactive, person-centred comprehensive geriatric assessments and personalised care planning for people as part of Kerrier Integrated Neighbourhood team, supporting anticipatory care and reducing unplanned admissions.

Complete personalised care and support plans and advanced care plans.

Act as a key link between community, primary, and acute services to promote seamless care for people living with frailty.

Support the reduction of inappropriate hospital admission, readmission and to reduce care burden.

Contribute to develop innovative ways of working to ensure people are cared for at the right time and in the right place.

About us

North Kerrier Integrated Neighbourhood Team is leading the way with other areas in Cornwall to align health services as part of the NHS 10 year plan.

North Kerrier East Primary Care Network (Leatside Health Centre and Veor Surgery) are a dynamic, friendly and supportive Primary Care Network with experienced dedicated clinicians, supporting training across all healthcare professions. Our neighbourhood supports a population of just over 70,000, providing services to the people living in our area. We have a strong focus on health promotion and personalised care, supporting people to make informed decisions about their health and social care.

What we can offer

• An excellent working environment and being part of an innovative and supportive multi professional clinical leadership and management team dedicated to providing high quality clinical care.
• Opportunities to be part of audit, research and leading service modernisation and improvements with the support of a dedicated quality lead.
• Regular reflective practice, clinical supervision, training, and professional development opportunities.

Job responsibilities

Please ensure you read the attached comprehensive job description and complete the attached application form as well as the online form.

Consult, assess and treat patients with complex needs, using comprehensive geriatric assessments digitally, ensuring holistic assessment, prompt treatment and crisis care planning to directly prevent unnecessary hospital admissions.

Obtain, analyse and interpret the patients history, presenting symptoms, physical findings and diagnostic information to develop an appropriate differential diagnosis, ensuring clinical systems are updated and the person's GP is aware of the plan and findings.

Actively participate in North Kerrier Multidisciplinary team meetings.

Develop interventions and strategies to maintain the person in their own home setting or as close to home as is safe and achievable whilst providing specialised advice concerning care and safety, prioritising work accordingly.

Undertake robust clinical enquiry using clinical reasoning and decision making to establish a safe and effective treatment and personalised care plan.

Maintain competence in prescribing according to the level of prescribing qualification and participate in regular continuing professional development in this role.

Ensure MDTs adhere to the Gold Standard Framework and lead MDT development and best practice across North Kerrier.

Ensure the right people participate in MDTs from the North Kerrier Neighbourhood teams.

Participate in GP huddles and any other Partnership MDT and promote effective ways of working;

Exercise a critical understanding of personal scope of practice and to identify when a patient requires escalation or referring on to other services.

Develop effective working relationships with the Palliative Care Team and embed new processes and ways of working if required, to avoid duplication and to enhance the patient and family experience.

For an informal discussion please contact Tessa Goodchild, PCN Business Manager, .

Person Specification Experience

• Significant experience of managing people in their own homes with complex health requirements and in a clinic setting;
• Significant understanding of frailty syndromes and proactive/anticipatory care;
• Significant experience of completing complex geriatric assessments and its application in the community;
• Can plan, manage, monitor, advise and review general frailty care programmes for patients in core areas, including disease states/ long term conditions identified by local Needs Assessment;
• Demonstrates accountability for delivering professional expertise and direct service provision;
• Demonstrates critical thinking skills underpinned from perspectives and different models;
• Experience of working multi disciplinary teams;
• Able to follow legal, ethical, professional and organisational policies/procedures and codes of conduct;
• Comprehensive digital skills to use different clinical systems; health applications for self supportive care; risk stratification tools and general Microsoft office suite products.
• Operate as a full member of the primary/community care team, including contributing service evaluation/improvement and research activity;
• Collaborator working collaboratively across team boundaries;
• Manage and co ordinate the care that individual patients receive, including through liaising with other members of the MDT and with patients' carers;
• Facilitate primary care activity, with a strong emphasis on prevention and early intervention, including through the delivery of public health advice (e.g. relating to physical activity, weight management and smoking cessation);
• Contribute to the use of healthcare technologies to optimise the integration of service delivery (across teams, sectors and settings) and patients access and continuity of care.

Qualifications

• Registered Nurse on the NMC register or HCPC.
• Significant evidence of clinical frailty and older peoples care;
• Completion of/or currently undertaking the degree in long term condition or RCN Nurse Practitioner diploma or the equivalent.
• Educated to degree level in a health related field.
• Evidence of continual professional development and the practical application of new skills to the workplace.
• Independent non medical prescriber

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.