Job description

Job responsibilities

Clinical Practice

You will work with the GPs to manage patients throughout the day who present with urgent requests and needs, requiring on-the-day assessment.

You will work within the practice team to deliver care co-ordination to patients identified as at-risk, with the aim of avoiding wherever possible hospital admission and to ensure that patients receive the requisite care in the most appropriate setting.

You will manage the process of clinical care co-ordination, undertaking surgery consultations and home visits. The provision of clinical input will be at the discretion of the GP partners. Clinical input could include aspects of managing long-term conditions holistically.

You will contribute to the identification of patients at risk of emergency hospital admissions, using of risk stratification tools as well as identification through GPs and multi-disciplinary team meetings.

You will ensure that follow-up and proactive planning takes place for at risk patients being discharged from acute care.

You will provide organisational support to the Practice which may include planning, implementing and evaluating care plans for patients on behalf of the Practice. You will need to liaise with the GPs in the process of writing any care plans and will ensure such plans are agreed with patients and shared appropriately.

You will be a point of contact for patients, carers and their families in relation to clinical management and care plans; you will signpost and liaise with other agencies including the voluntary sector on their behalf.

You will:

• Act as an autonomous clinician within competencies with the full support of our clinical team.
• Ensure your clinical practice is safe and effective, and remains within boundaries of competence.
• Undertake daily visits, including any emergency visits that arise, as requested by the doctors.
• Clinically examine and assess patient needs from a psychological perspective, and plan clinical care accordingly
• Take a comprehensive patient history, carry out physical examinations and use expert knowledge and clinical judgment to identify the potential diagnosis
• Refer patients for investigations and/or the appropriate specialist care where appropriate
• Use your experience to plan and provide skilled and competent care to meet patients health and social care needs, involving other members of the wider health care team as appropriate
• Ensure the provision of continuity of care including the planning of follow-up consultations or visits
• Assess and evaluate with patients, the effectiveness of the treatment and care provided and propose changes when indicated
• Support patients to adopt health promotion strategies that promote healthy lifestyles and apply principles of self-care
• Read OOH reports and hospital discharge letters, act on information therein.
• Follow up any complex hospital discharges on the next working day, including a visit to the patient if required
• Provide care for the presenting patient including initial history taking, recording observations, clinical assessment, diagnosis, evaluation and treatment recommendations
• Demonstrate safe, clinical decision-making and expert care, including assessment and diagnostic skills
• Prioritise and triage the needs of patients accordingly making any necessary referrals for investigations in the appropriate manner
• Participate in chronic disease management
• Discuss as appropriate any referral with a GP, where a referral to secondary care is indicated.

Liaising with patients, families and carers

• Ensure that all patients with a care plan know how to contact the appropriate help in times of need and act as a focal point of communication between them and other clinical and non-clinical members of the practice and community team.
• Understand and facilitate clinical activity as required to ensure optimal and timely clinical care is delivered to patients.
• Act as an information resource for patients, multi-disciplinary colleagues and other stakeholders.

Interfacing with other agencies

• Liaise with other agencies to enact care plans for patients. Direct and refer individuals, families and carers to the most appropriate agencies / services to support the implementation of their care plans.
• Contribute to the evaluation of patient outcomes using clinical experience and other patient experience tools.
• Actively participate in clinical discussions at multi-disciplinary meetings optimising clinical reasoning skills and other areas of provision.
• Maintain a strong working interface between the GPs, Practice Team, District Nurse Team and other key stakeholders, offering clinical support and advice to patients on at-risk lists.
• Support patients and help to develop and initiate self-management plans.
• Communicate self-management plans to other health care providers who may be involved in the acute care provision.
• Create and maintain contacts with voluntary organisations that may be able to help/support their cohort of patients e.g. Age Concern, Alzheimers Support, local Link schemes.
• Sign-post patients with administrative issues related to daily living to Social Services or Citizens Advice; consider a referral to the Social Prescribing service.

Clinical Governance

• Take an active clinical role in the processes for monitoring and improving the quality of care provided to patients. This includes risk management, clinical audit and compliance with CQC requirements.
• Understand, identify and appropriately refer any safeguarding concerns.
• Ensure that patients receive the information they need and are treated with dignity and respect.
• Co-operate with carrying out risk assessments and must adhere to safe systems of work. This includes understanding and adhering to the reporting procedures for clinical and non-clinical incidents/near misses. Post holder must attend relevant courses and mandatory updates, take a pro-active role in contributing to risk identification and management and be responsive to lessons learned from incidents and near misses.
• Report clinical and non-clinical incidents to Practice Manager, GPs and proactively manage risk to vulnerable adults.
• Promote an environment conducive to effective learning and to comply with statutory and mandatory responsibilities in line with current Local and National Monitoring requirements.

Managing and using Information

• Maintain accurate legible and contemporaneous records and written reports in line with Practice Policies and procedures and professional codes of conduct. This will include accurate documentation on clinical IT systems and electronic reporting systems.
• Ensure the maintenance of an accurate computerised database of at risk patients and input activity and outcomes measures in order to support service development and meet contractual requirements.

Management

• Organise and manage your own time according to delegated workload.
• Work independently and autonomously, providing, support and advice to individuals, within guidelines and protocols identified for the role

Quality/Clinical Governance/Research and Audit

• Maintain accurate and cotemporaneous records
• Record activity on a clinical data base for both Practice and the CCG.
• Assist in the monitoring and protecting of groups and individuals whose health and well-being may be at risk e.g.: vulnerable adults.
• Practice the principles and philosophy of individualised patient care in accordance with Practice Policy, procedures and regulatory bodies guidelines

Individual Patient Care

• Undertake specific clinical tasks as recognised from the preliminary clinical assessment and as appropriately delegated from other clinicians within primary care and neighbourhood teams.
• Ensure the needs and wishes of the individual are documented.
• Enable patients to reach their optimum level of independence.
• Meet a range of patient and carer needs, including clinical interventions where appropriate in order to prevent hospital admission or reduce length of stay.
• Communicate with individuals about routine and daily activities, this may include overcoming difficulties (eg. hearing/language)

Other Factors

• Uniform may need to be worn.
• The post is based at Forest Health Care GP Practice but will involve travel across the area, including lone working; you will need to have your own vehicle and appropriate car insurance.

In addition to the duties and responsibilities listed above, the post-holder may be required to assist with covering nursing staff during absence and to also perform other duties assigned by the GPs or Practice Manager when required.

See attached job description for full information.

Person Specification

Qualifications

Essential

• Qualified RGN
• Continuous membership of NMC.
• Evidence of training undertaken to enhance and maintain skills

Desirable

• Experience in consulting on minor illness.
• Ability to prescribe in accordance with agreed protocols.

Experience

Essential

• Minimum 5 years relevant nursing experience.
• Good interpersonal skills with patients and staff.
• Experienced in working within a computerised environment.
• Experienced in working autonomously.
• Able to work under pressure and prioritise workload.
• Understanding of the NHS and the current issues affecting general practice and primary care.

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.

UK Registration

Applicants must have current UK professional registration. For further information please see NHS Careers website .

Employer details

Employer name

Forest Health Care

Address

Cinderford Medical Centre

Valley Road

Cinderford

Gloucestershire

GL14 2NX