PCN NurseNHS

Job summary

Dartford Central Primary Care Network is looking for an experienced, compassionate and motivated Registered Nurse to join our developing frailty service through the Single Neighbourhood programme. Supporting a population of around 42,000 patients, you will work across our GP practices, patients homes and care homes to improve outcomes for people living with frailty and complex health needs. This is an exciting opportunity to help shape a proactive, joined-up approach to care, working alongside primary, community, social and specialist care colleagues. We are looking for someone who enjoys working autonomously, managing complex needs and building strong relationships with patients, carers and professionals. You will play an important role in helping people remain well and independent, receive the right care at the right time and avoid unnecessary hospital admissions.

Main duties of the job

As our PCN Nurse, you will:

• Provide proactive, holistic nursing assessment and care for adults living with frailty and complex health needs.
• Undertake Comprehensive Geriatric Assessments (CGAs) and develop personalised care plans with patients and carers.
• Identify and respond to deterioration, frailty-related concerns and changing health or care needs.
• Contribute to ReSPECT, anticipatory, palliative and end-of-life care planning, ensuring patients wishes and preferences are reflected.
• Support medicines optimisation and work closely with GPs, pharmacists and other healthcare professionals.
• Follow up patients after hospital discharge, acute illness or significant changes in their health.
• Work across GP practices, patients homes and care homes, supporting people to remain well and independent.
• Coordinate care between primary care, community services, social care, care homes and specialist teams.
• Contribute to MDT meetings, case discussions and proactive care planning.
• Maintain accurate clinical records using EMIS Web and work within NMC, safeguarding and clinical governance requirements.
• Contribute to quality improvement and the ongoing development of the Single Neighbourhood frailty service.

Job description

PCN Nurse

Employer: Dartford Central Primary Care Network

Hours: 37.5 hours per week

Contract: Fixed term until 31 March 2027

Salary: Negotiable depending on experience

Job Purpose:

The PCN Nurse will provide proactive, holistic nursing assessment and coordinated care for adults living with frailty and complex health needs across Dartford Central Primary Care Network.

The post holder will work across GP practices, patients homes and care home settings, with a particular focus on patients who are housebound, living with frailty, approaching the end of life or at increased risk of deterioration or unplanned hospital admission.

Working autonomously and as part of a wider multidisciplinary team (MDT), the Frailty Nurse will identify needs early, develop personalised care plans and coordinate appropriate support. The overall aim is to help patients remain as well and independent as possible, improve their experience of care and reduce avoidable crises, emergency department attendances and hospital admissions.

Main Duties and Responsibilities

Clinical Care

The post holder will

• Provide high-quality, person-centred nursing assessment and care for adults with frailty and complex health needs.
• Undertake Comprehensive Geriatric Assessments (CGAs), considering physical, psychological, functional and social needs.
• Develop, implement and review personalised care plans in partnership with patients, families, carers and other professionals.
• Identify patients at risk of deterioration and take appropriate action within professional scope of practice.
• Assess and support common frailty-related concerns, including falls, reduced mobility, delirium, continence problems, malnutrition, cognitive decline and medication-related issues.
• Undertake and document NEWS2 observations where clinically indicated and escalate concerns appropriately.
• Support medicines optimisation, working collaboratively with GPs, PCN pharmacists and other prescribers.
• Undertake appropriate cognitive assessments and support onward referral to memory or specialist services in accordance with local pathways.
• Recognise patients who may benefit from palliative or end-of-life care and support access to appropriate services.

Personalised and Anticipatory Care

• Support anticipatory care planning and discussions about patients future wishes and preferences.
• Contribute to ReSPECT discussions and documentation where appropriate.
• Support sensitive conversations with patients and families about future care, including preferred place of care and end-of-life wishes.
• Ensure care planning reflects what matters to the individual and promotes independence wherever possible.

Care Coordination and MDT Working

• Act as a clinical link for patients whose needs involve multiple services.
• Work collaboratively with GPs, practice teams, community nurses, pharmacists, therapists, social care, geriatric services, hospices, care homes and voluntary sector organisations.
• Contribute clinical expertise to MDT meetings, case discussions and joint care planning.
• Support appropriate follow-up following hospital discharge, acute illness or significant changes in a patients circumstances.
• Help patients, families and carers understand and access relevant health, social care and voluntary sector services.
• Work with care homes and community teams to support coordinated care and the principles of Enhanced Health in Care Homes.
• Promote effective communication between services to improve continuity of care and reduce fragmentation.

Quality, Governance and Service Development

The post holder will:

• Maintain clear, accurate and contemporaneous clinical records, including appropriate coding using EMIS Web.
• Support accurate identification and recording of frailty, dementia and palliative care needs.
• Work in accordance with safeguarding procedures, clinical governance requirements, relevant NICE guidance, CQC requirements and locally agreed policies and pathways.
• Maintain patient confidentiality and comply with GDPR and Information Governance requirements.
• Contribute to audit, quality improvement, service evaluation and relevant programme data collection.
• Participate in mandatory training, clinical supervision, appraisal and continuing professional development.
• Maintain current NMC registration and practise in accordance with the NMC Code.
• Contribute to the development and evaluation of the Single Neighbourhood frailty service.

Person Specification

The successful candidate will be a compassionate, motivated and confident Registered Nurse who is comfortable working independently while remaining an active member of a multidisciplinary team.

Essential

• Registered Nurse with current NMC registration.
• Relevant experience caring for adults with frailty, long-term conditions or complex healthcare needs.
• Ability to undertake holistic clinical assessments and develop personalised care plans.
• Understanding of the needs of older people, housebound patients and individuals with complex health needs.
• Ability to recognise deterioration, make appropriate clinical decisions within professional scope and escalate concerns when required.
• Excellent communication and interpersonal skills, including the ability to manage sensitive conversations with patients and families.
• Ability to work autonomously and manage and prioritise a varied caseload.
• Ability to work collaboratively with professionals across health and social care.
• Commitment to delivering safe, compassionate and person-centred care.
• Ability to maintain accurate and appropriate clinical records.

Desirable

• Experience of working in primary care, community nursing or care home settings.
• Experience or knowledge of Comprehensive Geriatric Assessment and proactive frailty management.
• Experience of anticipatory, palliative or end-of-life care.
• Experience or knowledge of ReSPECT planning.
• Experience supporting medicines optimisation.
• Experience using EMIS Web or a similar electronic clinical system.
• Experience of audit, quality improvement or service development.

Working Arrangements

The role will require flexibility to work across Dartford Central PCN practices and, where appropriate, in patients homes and care home settings.

The post holder will be expected to manage their workload effectively, maintain appropriate professional boundaries and work within their level of competence and professional scope of practice.

As the post forms part of the developing Single Neighbourhood programme, the post holder will have the opportunity to contribute ideas, clinical expertise and learning to help shape how the frailty service develops.

The post holder may also be required to undertake other reasonable duties consistent with the level and responsibilities of the role.

Contract

The position is funded through the Single Neighbourhood programme and is offered on a fixed-term basis until 31 March 2027. There may be potential for the role to continue beyond this date, subject to future funding and the ongoing requirements of the service.

About us

Dartford Central Primary Care Network (PCN) brings together GP practices across the Dartford area, providing joined-up care to a population of approximately 42,000 patients.