PCN Senior Community Nurse

Why Join Huntingdon PCN? • Work across four progressive GP practices serving approximately 47,000 patients. • Be part of a supportive multidisciplinary team including GPs, ACPs, pharmacists, physiotherapists and social prescribers. • Opportunity to develop specialist skills in frailty, long-term conditions and community-based care. • Protected learning time, clinical supervision and CPD opportunities. • Be involved in service improvement and the development of proactive care services. • Supportive culture focused on innovation, collaboration and patient-centred care. The Senior Community Nurse will contribute to: • Improving patient access to community-based care. • Supporting continuity of care for housebound patients. • Preventing avoidable deterioration and hospital admissions. • Reducing health inequalities. • Improving patient experience and outcomes. • Supporting proactive and preventative healthcare. Key Responsibilities Clinical Care Deliver high-quality nursing care to housebound and frail patients within their own homes. Undertake holistic assessments of patients with complex, multiple and unpredictable healthcare needs. Make autonomous clinical decisions based on assessment findings, professional knowledge and evidence-based practice. Carry out clinical observations, monitoring and evaluation of patient health status. Analyse assessment findings and formulate clinical judgements independently. Support the delivery of annual long-term condition reviews for housebound patients. Develop and implement personalised care plans in partnership with patients and carers. Support patients with the management of long-term conditions. Monitor treatment effectiveness and identify concerns requiring escalation. Undertake wound care, clinical monitoring and other nursing interventions within scope of practice. Recognise situations requiring medical review and appropriately escalate concerns. Promote preventative healthcare interventions including vaccinations, health promotion and lifestyle advice. Work within professional scope of practice whilst exercising a high degree of clinical judgement and accountability. Assess and support patients whose care may be affected by impaired capacity, escalating concerns appropriately. Support Mental Capacity Act assessments and Best Interest decision-making processes where required. Identify and address unmet health needs and gaps in preventative care. Recognise clinical deterioration and escalate concerns appropriately. Support admission avoidance through early identification and intervention. Assess and support patients living with frailty, multiple long-term conditions and complex care needs. Refer appropriately to community, secondary care and voluntary sector services. Participate in advance care planning discussions where appropriate. Support patients receiving palliative and end-of-life care in collaboration with the wider multidisciplinary team. Caseload Management Manage and prioritise an allocated caseload of housebound patients. Maintain oversight of patient reviews, follow-up actions and care plans. Coordinate ongoing care and services to maintain continuity of care. Monitor patient outcomes and escalate concerns appropriately. Ensure referrals, assessments and interventions are completed in a timely manner. Maintain accurate and up-to-date caseload records. Support proactive management of patients at risk of deterioration, hospital admission or safeguarding concerns. Review caseload complexity and priorities to ensure effective workload management. Multidisciplinary Working Work collaboratively with GP practices, ACPs, District Nursing Teams and community services. Participate in multidisciplinary team meetings and case discussions. Liaise closely with carers, families and care homes where appropriate. Work collaboratively with pharmacists, physiotherapists, social prescribers and Adult Social Care teams. Act as an advocate for patients requiring support from multiple agencies. Facilitate safe transitions of care and support discharge planning where appropriate. Contribute to coordinated, person-centred care planning. Digital Systems and Technology Maintain accurate and contemporaneous clinical records using SystmOne. Utilise SystmOne, Accurx and Microsoft applications to manage caseload activity, patient communication, reporting and service delivery. Maintain accurate electronic records in line with information governance requirements. Utilise Accurx to support patient and professional communication. Use Microsoft Outlook, Teams, Word and Excel to support service delivery. Monitor and manage clinical tasks, referrals and workflow systems. Produce reports, audit information and outcome data as required. Ensure compliance with information governance and confidentiality requirements. Demonstrate confidence and competence when using digital healthcare technologies. Leadership and Professional Practice Act as a professional role model. Support students, trainees and junior colleagues where appropriate. Participate in clinical supervision and reflective practice. Maintain professional registration and comply with NMC standards. Participate in continuing professional development activities. Contribute to service development and implementation of best practice. Promote a culture of learning, quality improvement and patient safety. Quality Improvement Participate in clinical audit and service evaluation activities. Support quality improvement initiatives across the PCN. Use outcome data to improve patient care and service delivery. Contribute to the development and review of clinical pathways and procedures. Safeguarding Responsibilities Act as an advocate for vulnerable patients. Identify and respond appropriately to safeguarding concerns. Recognise signs of abuse, neglect, self-neglect, exploitation, domestic abuse and carer breakdown. Undertake holistic assessments within the patient's home environment. Raise safeguarding concerns and referrals in line with local procedures. Work collaboratively with safeguarding teams, Adult Social Care and partner organisations. Support Mental Capacity Act processes and Best Interest decision-making where appropriate. Ensure safeguarding activity is accurately documented. Maintain up-to-date safeguarding knowledge and training. Job description Job responsibilities Why Join Huntingdon PCN? • Work across four progressive GP practices serving approximately 47,000 patients. • Be part of a supportive multidisciplinary team including GPs, ACPs, pharmacists, physiotherapists and social prescribers. • Opportunity to develop specialist skills in frailty, long-term conditions and community-based care. • Protected learning time, clinical supervision and CPD opportunities. • Be involved in service improvement and the development of proactive care services. • Supportive culture focused on innovation, collaboration and patient-centred care. The Senior Community Nurse will contribute to: • Improving patient access to community-based care. • Supporting continuity of care for housebound patients. • Preventing avoidable deterioration and hospital admissions. • Reducing health inequalities. • Improving patient experience and outcomes. • Supporting proactive and preventative healthcare. Key Responsibilities Clinical Care Deliver high-quality nursing care to housebound and frail patients within their own homes. Undertake holistic assessments of patients with complex, multiple and unpredictable healthcare needs. Make autonomous clinical decisions based on assessment findings, professional knowledge and evidence-based practice. Carry out clinical observations, monitoring and evaluation of patient health status. Analyse assessment findings and formulate clinical judgements independently. Support the delivery of annual long-term condition reviews for housebound patients. Develop and implement personalised care plans in partnership with patients and carers. Support patients with the management of long-term conditions. Monitor treatment effectiveness and identify concerns requiring escalation. Undertake wound care, clinical monitoring and other nursing interventions within scope of practice. Recognise situations requiring medical review and appropriately escalate concerns. Promote preventative healthcare interventions including vaccinations, health promotion and lifestyle advice. Work within professional scope of practice whilst exercising a high degree of clinical judgement and accountability. Assess and support patients whose care may be affected by impaired capacity, escalating concerns appropriately. Support Mental Capacity Act assessments and Best Interest decision-making processes where required. Identify and address unmet health needs and gaps in preventative care. Recognise clinical deterioration and escalate concerns appropriately. Support admission avoidance through early identification and intervention. Assess and support patients living with frailty, multiple long-term conditions and complex care needs. Refer appropriately to community, secondary care and voluntary sector services. Participate in advance care planning discussions where appropriate. Support patients receiving palliative and end-of-life care in collaboration with the wider multidisciplinary team. Caseload Management Manage and prioritise an allocated caseload of housebound patients. Maintain oversight of patient reviews, follow-up actions and care plans. Coordinate ongoing care and services to maintain continuity of care. Monitor patient outcomes and escalate concerns appropriately. Ensure referrals, assessments and interventions are completed in a timely manner. Maintain accurate and up-to-date caseload records. Support proactive management of patients at risk of deterioration, hospital admission or safeguarding concerns. Review caseload complexity and priorities to ensure effective workload management. Multidisciplinary Working Work collaboratively with GP practices, ACPs, District Nursing Teams and community services. Participate in multidisciplinary team meetings and case discussions. Liaise closely with carers, families and care homes where appropriate. Work collaboratively with pharmacists, physiotherapists, social prescribers and Adult Social Care teams. Act as an advocate for patients requiring support from multiple agencies. Facilitate safe transitions of care and support discharge planning where appropriate. Contribute to coordinated, person-centred care planning. Digital Systems and Technology Maintain accurate and contemporaneous clinical records using SystmOne. Utilise SystmOne, Accurx and Microsoft applications to manage caseload activity, patient communication, reporting and service delivery. Maintain accurate electronic records in line with information governance requirements. Utilise Accurx to support patient and professional communication. Use Microsoft Outlook, Teams, Word and Excel to support service delivery. Monitor and manage clinical tasks, referrals and workflow systems. Produce reports, audit information and outcome data as required. Ensure compliance with information governance and confidentiality requirements. Demonstrate confidence and competence when using digital healthcare technologies. Leadership and Professional Practice Act as a professional role model. Support students, trainees and junior colleagues where appropriate. Participate in clinical supervision and reflective practice. Maintain professional registration and comply with NMC standards. Participate in continuing professional development activities. Contribute to service development and implementation of best practice. Promote a culture of learning, quality improvement and patient safety. Quality Improvement Participate in clinical audit and service evaluation activities. Support quality improvement initiatives across the PCN. Use outcome data to improve patient care and service delivery. Contribute to the development and review of clinical pathways and procedures. Safeguarding Responsibilities Act as an advocate for vulnerable patients. Identify and respond appropriately to safeguarding concerns. Recognise signs of abuse, neglect, self-neglect, exploitation, domestic abuse and carer breakdown. Undertake holistic assessments within the patient's home environment. Raise safeguarding concerns and referrals in line with local procedures. Work collaboratively with safeguarding teams, Adult Social Care and partner organisations. Support Mental Capacity Act processes and Best Interest decision-making where appropriate. Ensure safeguarding activity is accurately documented. Maintain up-to-date safeguarding knowledge and training.