Job responsibilities

Reports to Advanced Clinical Practitioner/Hospice Outreach Service manager

Scope & Job Purpose

Hospice in the Weald are committed to supporting and developing its workforce. We recognise and value the importance of individual development and want our nurses and paramedics to train and develop into Clinical Nurse Specialists or Clinical Paramedic Specialists. These roles are demanding, and require a broad range of skills and competencies, however, they are very rewarding and will provide you with both skills and learning to meet the needs of our community and our organisational strategies.

Primary Job Purpose

To work as part of the multi-disciplinary team in HOS (Hospice Outreach Service) to deliver high quality care to patients with a life limiting illness in the community.

To offer the patient and those who care for them, the skills of a dedicated palliative care service which encompasses symptom control, social, emotional and spiritual care.

To offer advice, support and education to the primary health care team and other healthcare professionals on palliative care issues. Giving appropriate medications when immediate need is identified on community visits and supporting other community healthcare professionals with advice about safe medication administration when needed

To strive to help us extend our hospice reach to ensure we have the right people, providing right care at the right time

You will provide clinical advice and specialist support to other professionals on palliative care issues and play a significant role in helping patients to achieve their preferred place of care and their preferred place of death.

To participate in quality initiatives within the department.

Key Responsibilities

Deliverables/Outcomes

Take and analyse a clinical history in a relevant succinct and logical manner

Record concisely, accurately, confidentially and legibly the appropriate elements of the history, examination, results of investigations, differential diagnosis and management plan

Present cases clearly, consistently and professionally to the MDT contributing effectively in patient management

Assess the patients needs. Identify their goals and work with the patient and family towards achieving them

Interpret the results of investigations and discuss and liaise with colleagues to order them appropriately

Develop knowledge of the options for achieving control of symptoms and ability to advise the primary health care team

Develop an ability to explore the personal resources of families/carers in order to ensure patients are cared for in the place of their choice

Support, advise and coach carers at home in managing a relative whose condition is deteriorating

Recognise the impact of caring for dying patients on primary health care team colleagues and offer support

Demonstrate sensitivity and respect for patients and families from different religious and cultural background and sexual orientation

Demonstrate safe mobilisation, transfer and movement of patients in the community and how and where to obtain appropriate equipment

Recognise and manage palliative care emergencies

Bring closure to the nurse-patient relationship and provide for a safe transition to another care provider

To be involved with and support the Gold Standard Framework (GSF) meetings with GPs and in Care Homes and Nursing homes.

Attend weekly MDT meetings

Management and Leadership

Liaise closely with HOS Manager and wider team on control, distribution and management of clinical workload.

Be cognisant of the Hospice in the Wealds Three-Year Strategy and Operational Business Plan.

Work to maintain a high level of risk awareness about self and patient safety

Assist in the development of policies, procedures, and guidelines to continuously improve ways of working.

Support and empower our volunteers

Communication and Teamwork

Develop skills in managing complex communication issues with patients and families as a lone worker in the community;

Anticipate barriers to communication, and take action to improve the communication skills and strategies of the team

Seeks out different styles and methods of communicating to assist longer term needs and aims

Develop advanced communication skills

Write and maintain accurate notes/documentation and input computerised data, keeping all information up-to-date

Develop presentation skills, both oral and written.

Structure an interview using appropriate questioning, avoid jargon, using familiarlanguage, at patients own pace

Communicate both verbally and in writing to patients whose first language may not be English in a manner that they understand, using interpreters appropriately

Break bad news in steps appropriate to the understanding of the individual and be able to support distress

Demonstrate an understanding of the need to involve patients and carers in decision making, offering them informed choices, respecting their views

Manage dissatisfied patients/relatives, anticipating potential problems

Demonstrate negotiation and diplomacy skills and partnership working with external agencies

Demonstrate competent use of Electronic Patient Records and Hospice in the Weald IT systems

Education and Training

Education and Training

Participate in all learning opportunities offered and expected as part of the development programme, and apply own learning to the future development of practice

Share, articulate and reflect palliative care skills, enabling others to learn

Participate in planned teaching programmes

Develop teaching skills

Support new staff and clinical placements

Use relevant AV equipment;

Utilise experiential learning methods;

Consistently draw on research and literature to influence specialist palliative careteaching

Obtain evidence based literature from various sources;

Apply evidence to patient care;

Training and Development

Within 2 years to have completed the ACNS/ACPS framework and consolidated performance and practice at a CNS/CPS level.

Actively participate in the provision of supervision/reflective practice to colleagues to support engaging development opportunities.

Undertake Hospice mandatory training and participate in wider training and development opportunities

Act as a role model and mentor to colleagues and to be an ambassador to neighbouring health and social care providers, providing informal education and support to staff in their provision of palliative care.

Work collaboratively with the multi-professional team to provide training to care homes on End of Life Care as required.

Working with Due Diligence

Assist with the development of policies and procedures

Participate in forums for discussion on research and audit programmes

Support quality initiatives in local area

Participate in clinical governance initiatives e.g. clinical review

Engage in clinical supervision and self-reflection, and use this to improve care andPractice

Maintain professionalism through adherence to recognized Codes (e.g. NMC, GMC, HPC, HCPC) and work within the boundaries of Hospice in the Weald policies

Maintain professional development though the Hospice Annual Review process to continuously update and improve knowledge and competencies

General

All employees are required to undertake the following:

To make positive contributions to all internal and external quality and/or best practice measures/processes.

To fully participate in the annual appraisal process, to agree targets and objectives with line managers and to report on activity against agreed targets on a regular basis.

To fully comply at all times, with Hospice in the Weald policies and procedures and to take responsibility for own actions/inactions.

To fully comply with all mandatory and HITW role specific training requirements

To act in accordance with workplace legislation/requirements including Health and Safety, Equality and Diversity and Data Protection.

To share and model HITW values and expected behaviours at all times.

To participate in all employee engagement activities including team, departmental or other staff meetings as required

THIS JOB DESCRIPTION IS NOT EXHAUSTIVE AND IS SUBJECT TO REVIEW IN CONJUNCTION WITH THE POST HOLDER AND ACCORDING TO FUTURE CHANGES/DEVELOPMENTS IN THE SERVICE

PERSON SPECIFICATION

Qualifications

Registered Nurse (Level 1) or Registered Paramedic (HCPC)with 3 years post registration experience.

Evidence of ongoing Professional Development.

Experience

Proven track record of contemporaneous clinical practice.

Experience in Palliative and End of Life Care and Bereavement Support in a community setting (desirable)

Prepared and delivered education programmes to other healthcare professionals. (desirable)

Essential Skills

Ability to motivate and inspire others to achieve in a fast paced and challenging environment.

Takes the initiative and responds flexibly to change.

Delegates tasks appropriately.

Ability to develop rapport with a wide range of people and to act with credibility, tact and diplomacy.

High level of computer literacy skills including the use of mobile technology.

Ability to interpret situations from different angles and identify opportunities for improvement.

Forward thinking and proactive in decision making and in assessing risks and its mitigation.

Applies personal organisation strategies to prioritise and effectively manage workload within a team environment.

Personal Attributes

Passionate about providing individualised care

Dedicated to making a difference and changing peoples lives

Compassionate

High levels of enterprise, innovation and dedication

Maintains a calm disposition and positive outlook

Proactive team player

Ability to work well within and adapt to a changing environment

Willingness to travel to varying work locations

Forward thinking

Qualifications

Essential

• Registered Nurse (Level 1) or Registered Paramedic (HCPC)
• with 3 years post registration experience.
• Evidence of ongoing Professional Development.

Experience

Essential

• Proven track record of contemporaneous clinical practice.

Desirable

• Experience in Palliative and End of Life Care and Bereavement Support in a community setting
• Prepared and delivered education programmes to other healthcare professionals.

Personal Attributes

Essential

• Passionate about providing individualised care
• Dedicated to making a difference and changing peoples lives
• Compassionate
• High levels of enterprise, innovation and dedication
• Maintains a calm disposition and positive outlook
• Proactive team player
• Ability to work well within and adapt to a changing environment
• Willingness to travel to varying work locations
• Forward thinking

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 (opens in a new window).

Job responsibilities

Reports to Advanced Clinical Practitioner/Hospice Outreach Service manager

Scope & Job Purpose

Hospice in the Weald are committed to supporting and developing its workforce. We recognise and value the importance of individual development and want our nurses and paramedics to train and develop into Clinical Nurse Specialists or Clinical Paramedic Specialists. These roles are demanding, and require a broad range of skills and competencies, however, they are very rewarding and will provide you with both skills and learning to meet the needs of our community and our organisational strategies.

Primary Job Purpose

To work as part of the multi-disciplinary team in HOS (Hospice Outreach Service) to deliver high quality care to patients with a life limiting illness in the community.

To offer the patient and those who care for them, the skills of a dedicated palliative care service which encompasses symptom control, social, emotional and spiritual care.

To offer advice, support and education to the primary health care team and other healthcare professionals on palliative care issues. Giving appropriate medications when immediate need is identified on community visits and supporting other community healthcare professionals with advice about safe medication administration when needed

To strive to help us extend our hospice reach to ensure we have the right people, providing right care at the right time

You will provide clinical advice and specialist support to other professionals on palliative care issues and play a significant role in helping patients to achieve their preferred place of care and their preferred place of death.

To participate in quality initiatives within the department.

Key Responsibilities

Deliverables/Outcomes

Take and analyse a clinical history in a relevant succinct and logical manner

Record concisely, accurately, confidentially and legibly the appropriate elements of the history, examination, results of investigations, differential diagnosis and management plan

Present cases clearly, consistently and professionally to the MDT contributing effectively in patient management

Assess the patients needs. Identify their goals and work with the patient and family towards achieving them

Interpret the results of investigations and discuss and liaise with colleagues to order them appropriately

Develop knowledge of the options for achieving control of symptoms and ability to advise the primary health care team

Develop an ability to explore the personal resources of families/carers in order to ensure patients are cared for in the place of their choice

Support, advise and coach carers at home in managing a relative whose condition is deteriorating

Recognise the impact of caring for dying patients on primary health care team colleagues and offer support

Demonstrate sensitivity and respect for patients and families from different religious and cultural background and sexual orientation

Demonstrate safe mobilisation, transfer and movement of patients in the community and how and where to obtain appropriate equipment

Recognise and manage palliative care emergencies

Bring closure to the nurse-patient relationship and provide for a safe transition to another care provider

To be involved with and support the Gold Standard Framework (GSF) meetings with GPs and in Care Homes and Nursing homes.

Attend weekly MDT meetings

Management and Leadership

Liaise closely with HOS Manager and wider team on control, distribution and management of clinical workload.

Be cognisant of the Hospice in the Wealds Three-Year Strategy and Operational Business Plan.

Work to maintain a high level of risk awareness about self and patient safety

Assist in the development of policies, procedures, and guidelines to continuously improve ways of working.

Support and empower our volunteers

Communication and Teamwork

Develop skills in managing complex communication issues with patients and families as a lone worker in the community;

Anticipate barriers to communication, and take action to improve the communication skills and strategies of the team

Seeks out different styles and methods of communicating to assist longer term needs and aims

Develop advanced communication skills

Write and maintain accurate notes/documentation and input computerised data, keeping all information up-to-date

Develop presentation skills, both oral and written.

Structure an interview using appropriate questioning, avoid jargon, using familiarlanguage, at patients own pace

Communicate both verbally and in writing to patients whose first language may not be English in a manner that they understand, using interpreters appropriately

Break bad news in steps appropriate to the understanding of the individual and be able to support distress

Demonstrate an understanding of the need to involve patients and carers in decision making, offering them informed choices, respecting their views

Manage dissatisfied patients/relatives, anticipating potential problems

Demonstrate negotiation and diplomacy skills and partnership working with external agencies

Demonstrate competent use of Electronic Patient Records and Hospice in the Weald IT systems

Education and Training

Education and Training

Participate in all learning opportunities offered and expected as part of the development programme, and apply own learning to the future development of practice

Share, articulate and reflect palliative care skills, enabling others to learn

Participate in planned teaching programmes

Develop teaching skills

Support new staff and clinical placements

Use relevant AV equipment;

Utilise experiential learning methods;

Consistently draw on research and literature to influence specialist palliative careteaching

Obtain evidence based literature from various sources;

Apply evidence to patient care;

Training and Development

Within 2 years to have completed the ACNS/ACPS framework and consolidated performance and practice at a CNS/CPS level.

Actively participate in the provision of supervision/reflective practice to colleagues to support engaging development opportunities.

Undertake Hospice mandatory training and participate in wider training and development opportunities

Act as a role model and mentor to colleagues and to be an ambassador to neighbouring health and social care providers, providing informal education and support to staff in their provision of palliative care.

Work collaboratively with the multi-professional team to provide training to care homes on End of Life Care as required.

Working with Due Diligence

Assist with the development of policies and procedures

Participate in forums for discussion on research and audit programmes

Support quality initiatives in local area

Participate in clinical governance initiatives e.g. clinical review

Engage in clinical supervision and self-reflection, and use this to improve care andPractice

Maintain professionalism through adherence to recognized Codes (e.g. NMC, GMC, HPC, HCPC) and work within the boundaries of Hospice in the Weald policies

Maintain professional development though the Hospice Annual Review process to continuously update and improve knowledge and competencies

General

All employees are required to undertake the following:

To make positive contributions to all internal and external quality and/or best practice measures/processes.

To fully participate in the annual appraisal process, to agree targets and objectives with line managers and to report on activity against agreed targets on a regular basis.

To fully comply at all times, with Hospice in the Weald policies and procedures and to take responsibility for own actions/inactions.

To fully comply with all mandatory and HITW role specific training requirements

To act in accordance with workplace legislation/requirements including Health and Safety, Equality and Diversity and Data Protection.

To share and model HITW values and expected behaviours at all times.

To participate in all employee engagement activities including team, departmental or other staff meetings as required

THIS JOB DESCRIPTION IS NOT EXHAUSTIVE AND IS SUBJECT TO REVIEW IN CONJUNCTION WITH THE POST HOLDER AND ACCORDING TO FUTURE CHANGES/DEVELOPMENTS IN THE SERVICE

PERSON SPECIFICATION

Qualifications

Registered Nurse (Level 1) or Registered Paramedic (HCPC)with 3 years post registration experience.

Evidence of ongoing Professional Development.

Experience

Proven track record of contemporaneous clinical practice.

Experience in Palliative and End of Life Care and Bereavement Support in a community setting (desirable)

Prepared and delivered education programmes to other healthcare professionals. (desirable)

Essential Skills

Ability to motivate and inspire others to achieve in a fast paced and challenging environment.

Takes the initiative and responds flexibly to change.

Delegates tasks appropriately.

Ability to develop rapport with a wide range of people and to act with credibility, tact and diplomacy.

High level of computer literacy skills including the use of mobile technology.

Ability to interpret situations from different angles and identify opportunities for improvement.

Forward thinking and proactive in decision making and in assessing risks and its mitigation.

Applies personal organisation strategies to prioritise and effectively manage workload within a team environment.

Personal Attributes

Passionate about providing individualised care

Dedicated to making a difference and changing peoples lives

Compassionate

High levels of enterprise, innovation and dedication

Maintains a calm disposition and positive outlook

Proactive team player

Ability to work well within and adapt to a changing environment

Willingness to travel to varying work locations

Forward thinking

Qualifications

Essential

• Registered Nurse (Level 1) or Registered Paramedic (HCPC)
• with 3 years post registration experience.
• Evidence of ongoing Professional Development.

Experience

Essential

• Proven track record of contemporaneous clinical practice.

Desirable

• Experience in Palliative and End of Life Care and Bereavement Support in a community setting
• Prepared and delivered education programmes to other healthcare professionals.

Personal Attributes

Essential

• Passionate about providing individualised care
• Dedicated to making a difference and changing peoples lives
• Compassionate
• High levels of enterprise, innovation and dedication
• Maintains a calm disposition and positive outlook
• Proactive team player
• Ability to work well within and adapt to a changing environment
• Willingness to travel to varying work locations
• Forward thinking

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 (opens in a new window).

Job responsibilities

• Support public health and screening programmes, including immunisations, vaccinations, where appropriate.

  Completing CGAs and Respect forms.

  Deliver expert nursing assessments and manage complex care needs of housebound and care home residents within Weald PCN in partnership with GP.

  Deliver a range of nurse-led clinics and undertake housebound and care home visits, including providing vaccinations.

  Create a trusting partnership with patients and/or relatives/carers to communicate and explain complex medical issues

  Mentor, support, and supervise new-to-general-practice nurses, student nurses, and other healthcare professionals (e.g., nursing associates, HCSWs) across the PCN by agreement and when appropriate.

  Be proficient in use of digital technologies applicable in the workplace to enhance personalised care.

  Advocate for people and nursing.

  Undertake mandatory training and CPD to meet NMC revalidation and practice needs.

  Provide clinical support and guidance to care home staff to improve patient safety and health outcomes.

  Identify own personal development needs, proactively seek feedback, and take effective action to address them using a mix of strategies.

  Work collaboratively across the PCN, actively engaging with community services, secondary care, social care, and voluntary sector providers to ensure integrated and holistic care pathways.

  Reflect on learning using appropriate frameworks (e.g. NMC Code).

  Adhere to CQC standards, infection prevention and control protocols, and safeguarding responsibilities.

  Participate in audits, significant event reviews, and quality improvement initiatives.

  Maintain confidentiality, information governance, and data protection in line with NHS standards.

  Recognise and work within own competence and professional code of conduct as regulated by the NMC.

  Ensure that their own practice is kept updated, using an acceptable model of clinical supervision.

  Take every opportunity to expand individual practice in line with the principles contained within the Nursing and Midwifery Councils (NMC) document The Code (2015) (or equivalent professional body).

Other

Essential

• Self-directed practitioner
• Highly motivated
• Committed to continuous professional development
• Flexible
• Enthusiastic
• Partner collaboratively with multidisciplinary teams, individuals, families and carers to make clinical decisions.
• Conscious of the need to act sustainably.
• Able and willing to travel to various care homes within the Ridge locality.
• Must have a clean driving license and access to a vehicle.

Qualifications

Essential

• Degree in Nursing or Registered Nurse Degree
• Registered with Nursing and Midwifery Council
• More than one post-registration qualifications and CPD, for example certificates, diplomas or professional development courses at level 6 (e.g. long-term conditions care and/or public health initiatives)

Skills

Essential

• Clinical examination skills
• Ability to use clinical systems (Emis)
• Ability to use Microsoft 365 products (Outlook, Word, Excel).
• Ability to communicate and compassion and integrity.
• Conflict management skills
• Able to combine theory and practical skills to develop nursing practice and judgment.

Knowledge

Essential

• Management of patients with long-term conditions
• Management of patients with complex needs
• Local plan and national health policy
• Understanding of a range of assessment methods.

Desirable

• Knowledge of public health issues in the area
• Project management

Experience

Essential

• Experienced level of practice
• Working within frailty or management of patients with long-term conditions
• Primary Care or Community nursing experience
• Nurse-led management of minor illness, minor ailments and injuries
• Audit
• Research
• Clinical Leadership

Desirable

• Nursing in care home settings
• Nurse prescribing
• Experience in clinical leadership

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 (opens in a new window).

Job responsibilities

Core responsibilities

Clinical practice

The role will mainly involve working in our Same Day Access Hub seeing patients for urgent on the day issues. The role will involve working alongside PCN team of GP supervisor / Paramedic Practitioner in the PCN Same Day Access Hub seeing patients on the day with urgent issues.

The post may include cross cover with the award-winning Frailty Visiting Team visiting patients who are housebound for urgent on the day issues.

Work as part of a multi-disciplinary team to deliver safe and high-quality care.

Carry out clinical practice at an advanced level using expert clinical skills, critical judgements & knowledge to deliver appropriate and safe care.

Assess, diagnose, plan, implement and evaluate treatment/interventions and care for patients presenting with acute, long term and complex health needs.

Manage undifferentiated undiagnosed condition and identify red flags

and underlying serious pathology and take appropriate action

Triage and treat patients, including same day triage, performing assessment of their needs and makes referrals as necessary to other members of the primary and secondary health care teams as appropriate.

Interpret investigation findings to determine effective treatment plans & discuss with GPs where a second opinion is required

Proactively identify, diagnose and manage treatment plans for patients at risk of developing a long-term condition, using both non-pharmacological and pharmacological treatments.

Co-ordinate the planning and delivery of care ensuring patients and carers or relatives are involved where required. Actively take a personalised care approach and population centre care approach to enable shared decision making.

Prescribing and reviewing medication that is appropriate for patient needs and in accordance with latest evidence-based practice, national and practice protocols and within the scope of qualified practice.

Diagnose and manage acute and chronic conditions, including drug and non-drug based treatment methods into a management plan.

Request diagnostic investigations and interpret within agreed protocols e.g. x-ray, blood tests, scans, etc.

Assess, diagnose and treat patients in practice premises or their own home who require medical attention and/or refer to appropriate agency.

Refer patients to other members of the multi-disciplinary practice teams, secondary care organisations and other organisations as necessary.

Communication

Uses and adapts communication style to meet individual patient needs to ensure patients are fully informed about treatment.

Communicates effectively with patients and carers, recognising the need for alternative methods of communication to overcome different levels of understanding, cultural background and preferred ways of communicating

Anticipates barriers to communication and take action to improve communication

Maintains effective communication with the primary care team and with external stakeholders

Ensures awareness of sources of support and guidance and provides information in an acceptable format to all patients, recognising any difficulties and referring where appropriate.

Safeguarding adults and children

The postholder has a duty to safeguard and promote the welfare of vulnerable adults and children.

When adults or children and/or their carers use primary care services, it is essential that all adult and child protection concerns are both recognised and acted on appropriately.

The postholder has a responsibility to ensure they are familiar with and follow local policies in relation to safeguarding vulnerable adults and that they follow the local child protection procedures and any supplementary guidance.

The postholder has a responsibility to support appropriate investigations either internally or externally.

To ensure the postholder is equipped to carry out their duties effectively, they must also attend vulnerable adult and child protection training and updates at the competency level appropriate to the work they do and in accordance with the local vulnerable adult and child protection training guidance.

Leadership and management personal and people development

Takes responsibility for own learning and performance including participating in clinical supervision and acting as a positive role model

Supports staff development in order to maximise potential and support practice development

Critically evaluates and reviews innovations and developments that are relevant to clinical practice

Contributes to the development of local guidelines, protocols and standards

Maintains effective communication with those responsible for the overall commissioning and procurement process

Promotes the role of the Advanced Clinical Practitioner in general practicecompleting relevant training in order to provide multi-professional clinical practice and CPD supervision to other roles within primary care.

Team working

Understands own role and scope and identify how this may develop over time

Works as an effective and responsible team member, supporting others and exploring the mechanisms to develop new ways of working

Creates and agrees clear referral mechanisms to meet patient need

Prioritises own workload and uses effective time-management strategies to complete work within agreed timescales

Discusses, highlights and works with the team to create opportunities to improve patient care

Manages and leads the delivery of specifically identified services or projects as agreed with the PCN Clinical Director and the PCN management team

Education

Undertakes mentorship for more junior staff, assessing competence against set standards

Use evidence-based strategies to improve and enhance the quality of patient care

Assesses own learning needs and undertakes learning as appropriate

Provides an educational role to patients, carers, families and colleagues in an environment that facilitates learning

Research

Critically engage in research activity and use evidence-based strategies to improve and enhance the quality of patient care

Participates in clinical governance activity and contributes to the improvement in quality of health outcomes through audit, risk management and the Quality and Outcomes Framework

Participates in investigation of incidents and events as required.

Identifies, applies and disseminates research findings relating to own practice

Collects data for audit purposes and uses clinical audit to monitor quality in the service and implements change according to findings.

Participates in clinical trials and equipment testing.

Meets timescales/deadlines for audits and written returns to ensure that the Practice meets quality standards and receives the designated funding (e.g. Quarterly Enhanced Services returns, annual QOF audit

Quality

Under supervision and support of GPs in the practice, the post-holder will strive to maintain quality within the practices, and will:

Participates in clinical governance activity and contribute to the improvement in quality of health outcomes through audit, risk management and the Quality and Outcomes Framework

Alerts other team members to concerns about risk, quality and safety.

Participates in investigation of incidents and events as required.

Contributes to the effectiveness of the team by reflecting on own and team activities and making suggestions on ways to improve and enhance the teams performance

Works effectively with individuals in other agencies to meet patients needs

Effectively manages own time, workload and resources.

Delivery of care in line with NSF, NICE guidelines and evidence-based care

See attached job description and person specification for further details.

Knowledge

Essential

• A clear understanding of the Multi-professioanl framework for advanced clinical practice in England
• Advanced clinical practice skills
• Clinical examination skills
• Accountability of own role and other roles
• Management of patients with long-term conditions
• Management of patients with complex needs
• Local plan and national health policy
• Wider health economy
• Clinical governance issues in primary care
• Patient group directions and associated policy
• Knowledge/experience in general practice/elderly care or palliative care

Desirable

• Able to identify determinants on health in the area
• Knowledge of public health issues in the area

Personal qualities

Essential

• Self-directed practitioner
• Highly motivated
• Flexibility
• Enthusiasm
• Team player

Skills

Essential

• Clinical leadership skills
• Communication skills, both written and verbal
• Communication of difficult messages to patients and families
• Negotiation and conflict management skills
• Change management
• Teaching and mentorship within a clinical setting
• Resource management

Experience

Essential

• Significant post registration experience
• Recent primary or community experience
• Management of minor illness, minor ailments and injuries
• Triage
• Compiling protocols and clinical guidelines
• Clinical Leadership
• Audit
• Research

Desirable

• Project management
• Health-needs assessment

Qualifications

Essential

• Masters degree level in the relevant area of expertise
• for Advanced Clinical Practitioner Nurses only, have either graduated from a Centre for Advancing Practice accredited MSc advanced practice programme or completed the Centres ePortfolio (supported) Route
• MSc in advanced practice or equivalent accreditation
• Independent prescribing qualification
• for advanced practice pharmacists only, qualified from an approved 18-month training pathway or equivalent and qualified as an independent prescriber

Desirable

• Mentor/teaching qualification
• Clinical supervision training and experience

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 (opens in a new window).

Job responsibilities

• Support public health and screening programmes, including immunisations, vaccinations, where appropriate.
• Completing CGAs and Respect forms.
• Deliver expert nursing assessments and manage complex care needs of housebound and care home residents within Tonbridge PCN in partnership with GP.
• Support patient and public involvement to enhance patient care and service delivery.
• Deliver a range of nurse-led clinics and undertake housebound and care home visits, including providing vaccinations and, where appropriately trained, carrying out procedures such as FeNO testing, ECGs, ear irrigation, and other clinical interventions.
• Create a trusting partnership with patients and/or relatives/carers to communicate and explain complex medical issues
• Mentor, support, and supervise new-to-general-practice nurses, student nurses, and other healthcare professionals (e.g., nursing associates, HCSWs) across the PCN by agreement and when appropriate.
• Be proficient in use of digital technologies applicable in the workplace to enhance personalised care.
• Advocate for people and nursing.
• Undertake mandatory training and CPD to meet NMC revalidation and practice needs.
• Provide clinical support and guidance to care home staff to improve patient safety and health outcomes.
• Identify own personal development needs, proactively seek feedback, and take effective action to address them using a mix of strategies.
• Work collaboratively across the PCN, actively engaging with community services, secondary care, social care, and voluntary sector providers to ensure integrated and holistic care pathways.
• Reflect on learning using appropriate frameworks (e.g. NMC Code).
• Adhere to CQC standards, infection prevention and control protocols, and safeguarding responsibilities.
• Participate in audits, significant event reviews, and quality improvement initiatives.
• Maintain confidentiality, information governance, and data protection in line with NHS standards.
• Recognise and work within own competence and professional code of conduct as regulated by the NMC.
• Ensure that their own practice is kept updated, using an acceptable model of clinical supervision.
• Take every opportunity to expand individual practice in line with the principles contained within the Nursing and Midwifery Councils (NMC) document The Code (2015) (or equivalent professional body).

Other

Essential

• Self-directed practitioner
• Highly motivated
• Committed to continuous professional development
• Flexible
• Enthusiastic
• Partner collaboratively with multidisciplinary teams, individuals, families and carers to make clinical decisions.
• Conscious of the need to act sustainably.
• Able and willing to travel to various care homes within the Ridge locality.
• Must have a clean driving license and access to a vehicle.

Qualifications

Essential

• Degree in Nursing or Registered Nurse Degree
• Registered with Nursing and Midwifery Council
• More than one post-registration qualifications and CPD, for example certificates, diplomas or professional development courses at level 6 (e.g. long-term conditions care and/or public health initiatives)

Skills

Essential

• Clinical examination skills
• Ability to use clinical systems (Emis)
• Ability to use Microsoft 365 products (Outlook, Word, Excel).
• Ability to communicate and compassion and integrity.
• Conflict management skills
• Able to combine theory and practical skills to develop nursing practice and judgment.

Knowledge

Essential

• Management of patients with long-term conditions
• Management of patients with complex needs
• Local plan and national health policy
• Understanding of a range of assessment methods.

Desirable

• Knowledge of public health issues in the area
• Project management

Experience

Essential

• Experienced level of practice
• Working within frailty or management of patients with long-term conditions
• Primary Care or Community nursing experience
• Nurse-led management of minor illness, minor ailments and injuries
• Audit
• Research
• Clinical Leadership

Desirable

• Nursing in care home settings
• Nurse prescribing
• Experience in clinical leadership

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 (opens in a new window).

Job responsibilities

Clinical practice

• Provide autonomous clinical assessment, diagnosis, prescribing, and management of residents in care homes, including those with complex, acute, chronic, frailtyrelated, or undifferentiated presentations.
• Lead proactive care home ward rounds, reviewing routine followups, postdischarge cases, longterm conditions, and residents identified as at risk of deterioration.
• Creating and reviewing personalised care plans, including Comprehensive Geriatric Assessments (CGA) and ReSPECT discussions in collaboration with MDT and families.
• Work as part of a multi-disciplinary team to deliver safe and high-quality care.
• Conduct clinical practice at an advanced level using expert clinical skills, critical judgements & knowledge to deliver appropriate and safe care.
• Assess, diagnose, plan, implement and evaluate treatment/interventions and care for patients presenting with acute, long term and complex health needs.
• Interpret investigation findings to determine effective treatment plans & discuss with GPs where a second opinion is required.
• Proactively identify, diagnose, and manage treatment plans for patients at risk of developing a long-term condition, using both non-pharmacological and pharmacological treatments.
• Co-ordinate the planning and delivery of care ensuring patients and carers or relatives are involved where required. Actively take a personalised care approach and population centre care approach to enable shared decision making.
• Prescribing and reviewing medication that is appropriate for patient needs and in accordance with latest evidence-based practice, national and practice protocols and within the scope of qualified practice.
• Diagnose and manage acute and chronic conditions, including drug and non-drug-based treatment methods into a management plan.
• Request diagnostic investigations and interpret within agreed protocols e.g. x-ray, blood tests, scans, etc.
• Refer patients to other members of the multi-disciplinary practice teams, secondary care organisations, and other organisations, as necessary.
• The postholder has a duty to safeguard and promote the welfare of vulnerable adults and children.

Leadership and management personal and people development

• Takes responsibility for own learning and performance including participating in clinical supervision and acting as a positive role model.
• Supports staff development to maximise potential and support practice development.
• Critically evaluates and reviews innovations and developments that are relevant to clinical practice.
• Contributes to the development of local guidelines, protocols, and standards.
• Maintains effective communication with those responsible for the overall commissioning and procurement process.
• Promotes the role of the Advanced Clinical Practitioner in general practicecompleting relevant training to provide multi-professional clinical practice and CPD supervision to other roles within primary care.
• Works as an effective and responsible team member, supporting others and exploring the mechanisms to develop new ways of working.

Education

• Undertakes mentorship for more junior staff, assessing competence against set standards.
• Use evidence-based strategies to improve and enhance the quality of patient care.
• Assesses own learning needs and undertakes learning as appropriate.
• Provides an educational role to patients, carers, families, and colleagues in an environment that facilitates learning.

Research

• Critically engage in research activity and use evidence-based strategies to improve and enhance the quality of patient care.
• Participates in clinical governance activity and contributes to the improvement in quality of health outcomes through audit, risk management and the Quality and Outcomes Framework
• Participates in investigation of incidents and events as required.
• Identifies, applies, and disseminates research findings relating to own practice.
• Collects data for audit purposes and uses clinical audit to monitor quality in the service and implements change according to findings.
• Participates in clinical trials and equipment testing.

Quality

Under supervision and support of GPs in the practice, the post-holder will strive to maintain quality within the practices, and will:

• Participate in clinical governance activity and contribute to the improvement in quality of health outcomes through audit, risk management and the Quality and Outcomes Framework
• Alerts other team members to concerns about risk, quality, and safety.
• Participates in investigation of incidents and events as required.
• Contributes to the effectiveness of the team by reflecting on own and team activities and making suggestions on ways to improve and enhance the teams performance.
• Works effectively with individuals in other agencies to meet patients needs.
• Effectively manages own time, workload, and resources.
• Delivery of care in line with NSF, NICE guidelines, and evidence-based care

Skills

Essential

• Clinical leadership skills
• Communication skills, both written and verbal
• Communication of difficult messages to patients and families
• Negotiation and conflict management skills
• Change management.
• Teaching and mentorship within a clinical setting
• Resource management

Other

Essential

• Self-directed practitioner
• Highly motivated
• Flexibility
• Enthusiasm
• Collaborator
• You will be required to travel independently between care homes and PCN sites, therefore having access to your own reliable transport is essential. A full, clean UK driving licence (or equivalent) is required to safely and efficiently perform the duties of the role.

Qualifications

Essential

• Masters degree level in the relevant area of expertise
• For Advanced Clinical Practitioner Nurses only, have either graduated from a Centre for Advancing Practice accredited MSc advanced practice programme or completed the Centres ePortfolio (supported) Route.
• MSc in advanced practice or equivalent accreditation
• Independent prescribing qualification

Desirable

• Mentor/teaching qualification.
• Clinical supervision training and experience

Experience

Essential

• Significant post registration experience
• Recent primary or community experience
• Management of minor illness, minor ailments, and injuries
• Triage
• Compiling protocols and clinical guidelines
• Clinical Leadership
• Audit
• Research

Desirable

• Project management
• Health-needs assessment

Knowledge

Essential

• A clear understanding of the Multi-professional framework for advanced clinical practice in England (https://advanced-practice.hee.nhs.uk/wp-content/uploads/sites/28/2025/05/Multi-professional-framework-for-advanced-practice-in-England--Edition-2025.pdf)
• Advanced clinical practice skills
• Clinical examination skills
• Accountability of own role and other roles
• Management of patients with long-term conditions
• Management of patients with complex needs
• Local plan and national health policy
• Wider health economy
• Clinical governance issues in primary care
• Patient group directions and associated policy
• Knowledge/experience in general practice/elderly care or palliative care

Desirable

• Able to identify determinants on health in the area.
• Knowledge of public health issues in the area

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 (opens in a new window).

Job responsibilities

Core responsibilities

Clinical practice

The role will mainly involve working in our Same Day Access Hub seeing patients for urgent on the day issues. The role will involve working alongside PCN team of GP supervisor / Paramedic Practitioner in the PCN Same Day Access Hub seeing patients on the day with urgent issues.

The post may include cross cover with the award-winning Frailty Visiting Team visiting patients who are housebound for urgent on the day issues.

Work as part of a multi-disciplinary team to deliver safe and high-quality care.

Carry out clinical practice at an advanced level using expert clinical skills, critical judgements & knowledge to deliver appropriate and safe care.

Assess, diagnose, plan, implement and evaluate treatment/interventions and care for patients presenting with acute, long term and complex health needs.

Manage undifferentiated undiagnosed condition and identify red flags

and underlying serious pathology and take appropriate action

Triage and treat patients, including same day triage, performing assessment of their needs and makes referrals as necessary to other members of the primary and secondary health care teams as appropriate.

Interpret investigation findings to determine effective treatment plans & discuss with GPs where a second opinion is required

Proactively identify, diagnose and manage treatment plans for patients at risk of developing a long-term condition, using both non-pharmacological and pharmacological treatments.

Co-ordinate the planning and delivery of care ensuring patients and carers or relatives are involved where required. Actively take a personalised care approach and population centre care approach to enable shared decision making.

Prescribing and reviewing medication that is appropriate for patient needs and in accordance with latest evidence-based practice, national and practice protocols and within the scope of qualified practice.

Diagnose and manage acute and chronic conditions, including drug and non-drug based treatment methods into a management plan.

Request diagnostic investigations and interpret within agreed protocols e.g. x-ray, blood tests, scans, etc.

Assess, diagnose and treat patients in practice premises or their own home who require medical attention and/or refer to appropriate agency.

Refer patients to other members of the multi-disciplinary practice teams, secondary care organisations and other organisations as necessary.

Communication

Uses and adapts communication style to meet individual patient needs to ensure patients are fully informed about treatment.

Communicates effectively with patients and carers, recognising the need for alternative methods of communication to overcome different levels of understanding, cultural background and preferred ways of communicating

Anticipates barriers to communication and take action to improve communication

Maintains effective communication with the primary care team and with external stakeholders

Ensures awareness of sources of support and guidance and provides information in an acceptable format to all patients, recognising any difficulties and referring where appropriate.

Safeguarding adults and children

The postholder has a duty to safeguard and promote the welfare of vulnerable adults and children.

When adults or children and/or their carers use primary care services, it is essential that all adult and child protection concerns are both recognised and acted on appropriately.

The postholder has a responsibility to ensure they are familiar with and follow local policies in relation to safeguarding vulnerable adults and that they follow the local child protection procedures and any supplementary guidance.

The postholder has a responsibility to support appropriate investigations either internally or externally.

To ensure the postholder is equipped to carry out their duties effectively, they must also attend vulnerable adult and child protection training and updates at the competency level appropriate to the work they do and in accordance with the local vulnerable adult and child protection training guidance.

Leadership and management personal and people development

Takes responsibility for own learning and performance including participating in clinical supervision and acting as a positive role model

Supports staff development in order to maximise potential and support practice development

Critically evaluates and reviews innovations and developments that are relevant to clinical practice

Contributes to the development of local guidelines, protocols and standards

Maintains effective communication with those responsible for the overall commissioning and procurement process

Promotes the role of the Advanced Clinical Practitioner in general practicecompleting relevant training in order to provide multi-professional clinical practice and CPD supervision to other roles within primary care.

Team working

Understands own role and scope and identify how this may develop over time

Works as an effective and responsible team member, supporting others and exploring the mechanisms to develop new ways of working

Creates and agrees clear referral mechanisms to meet patient need

Prioritises own workload and uses effective time-management strategies to complete work within agreed timescales

Discusses, highlights and works with the team to create opportunities to improve patient care

Manages and leads the delivery of specifically identified services or projects as agreed with the PCN Clinical Director and the PCN management team

Education

Undertakes mentorship for more junior staff, assessing competence against set standards

Use evidence-based strategies to improve and enhance the quality of patient care

Assesses own learning needs and undertakes learning as appropriate

Provides an educational role to patients, carers, families and colleagues in an environment that facilitates learning

Research

Critically engage in research activity and use evidence-based strategies to improve and enhance the quality of patient care

Participates in clinical governance activity and contributes to the improvement in quality of health outcomes through audit, risk management and the Quality and Outcomes Framework

Participates in investigation of incidents and events as required.

Identifies, applies and disseminates research findings relating to own practice

Collects data for audit purposes and uses clinical audit to monitor quality in the service and implements change according to findings.

Participates in clinical trials and equipment testing.

Meets timescales/deadlines for audits and written returns to ensure that the Practice meets quality standards and receives the designated funding (e.g. Quarterly Enhanced Services returns, annual QOF audit

Quality

Under supervision and support of GPs in the practice, the post-holder will strive to maintain quality within the practices, and will:

Participates in clinical governance activity and contribute to the improvement in quality of health outcomes through audit, risk management and the Quality and Outcomes Framework

Alerts other team members to concerns about risk, quality and safety.

Participates in investigation of incidents and events as required.

Contributes to the effectiveness of the team by reflecting on own and team activities and making suggestions on ways to improve and enhance the teams performance

Works effectively with individuals in other agencies to meet patients needs

Effectively manages own time, workload and resources.

Delivery of care in line with NSF, NICE guidelines and evidence-based care

See attached job description and person specification for further details.

Knowledge

Essential

• A clear understanding of the Multi-professioanl framework for advanced clinical practice in England
• Advanced clinical practice skills
• Clinical examination skills
• Accountability of own role and other roles
• Management of patients with long-term conditions
• Management of patients with complex needs
• Local plan and national health policy
• Wider health economy
• Clinical governance issues in primary care
• Patient group directions and associated policy
• Knowledge/experience in general practice/elderly care or palliative care

Desirable

• Able to identify determinants on health in the area
• Knowledge of public health issues in the area

Personal qualities

Essential

• Self-directed practitioner
• Highly motivated
• Flexibility
• Enthusiasm
• Team player

Skills

Essential

• Clinical leadership skills
• Communication skills, both written and verbal
• Communication of difficult messages to patients and families
• Negotiation and conflict management skills
• Change management
• Teaching and mentorship within a clinical setting
• Resource management

Experience

Essential

• Significant post registration experience
• Recent primary or community experience
• Management of minor illness, minor ailments and injuries
• Triage
• Compiling protocols and clinical guidelines
• Clinical Leadership
• Audit
• Research

Desirable

• Project management
• Health-needs assessment

Qualifications

Essential

• Masters degree level in the relevant area of expertise
• for Advanced Clinical Practitioner Nurses only, have either graduated from a Centre for Advancing Practice accredited MSc advanced practice programme or completed the Centres ePortfolio (supported) Route
• MSc in advanced practice or equivalent accreditation
• Independent prescribing qualification
• for advanced practice pharmacists only, qualified from an approved 18-month training pathway or equivalent and qualified as an independent prescriber

Desirable

• Mentor/teaching qualification
• Clinical supervision training and experience

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 (opens in a new window).