PCN Senior Community Nurse

The Senior Community Nurse will provide expert,patient-centred nursing care to frail, vulnerable and housebound patientsacross Huntingdon PCN. Working autonomously, the post holder will undertakecomprehensive assessments, develop and evaluate complex care plans, manage adefined caseload and make independent clinical decisions within theirprofessional scope of practice. As a senior member of the multidisciplinary team, thepost holder will provide clinical leadership, support less experiencedcolleagues and contribute to service development, quality improvement andproactive population health management. This post is suitable for an experienced nurse able towork autonomously within the community setting, exercising independent clinicaljudgement, managing clinical risk and leading the coordination of care forpatients with complex and multiple healthcare needs. Main duties of the job The role has a strong focus on proactive long-termcondition (LTC) management, personalised care planning and supporting patientsto maintain their independence and wellbeing within their own homes. The post holder will undertake nursing assessments,clinical observations, ongoing monitoring and evaluation of care for patientswith complex and long-term conditions, ensuring care is delivered in accordancewith local and national guidelines and evidence-based practice. They willcontribute to the delivery of annual long-term condition reviews for houseboundpatients, support proactive care planning and work closely with patients,carers and the wider multidisciplinary team. The Senior Community Nurse will hold responsibilityand accountability for effective management of a complex caseload of frail,vulnerable patients, prioritising interventions and independently coordinatingcare across multiple services. They will work closely with teams to supportimproved patient outcomes. The role requires excellent communication,organisational and digital skills. The post holder will use SystmOne, Accurxand Microsoft Office applications, including Outlook and Teams, to supporteffective communication, record keeping, reporting and service delivery. About us Our Vision and Values Huntingdon PCNs vision is to bring GP practicestogether with other local services to provide the best care in the right place.This role will support Huntingdon PCN which covers four GP Practices and have apatient population of 47,000 patients. Our values are: Integrity - We promise to conduct ourselves with the utmostintegrity, staying open and honest with colleagues and patients. Empathy - We strive to take perspective of and feel emotionsof another person, taking action to alleviate stress and pain of others showingkindness and care in our approach. Putting ourselves in other peoples shoes,both patients and colleagues, establishing an empathetic connection. Empowerment - We seek to champion positive relationships andbuild trust whilst empowering others 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. 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 patients 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. Person Specification Personal Qualities & Attributes * Compassionate and patient-centred approach to care * Ability to reflect on and share best practice with peers * Commitment to reducing health inequalities and improving patient outcomes * Ability to work collaboratively within a multidisciplinary team * Proactive and self-motivated approach to problem solving * Adaptable and resilient when managing competing priorities * Professional, approachable and trustworthy * Commitment to continuous learning and professional development Knowledge * Strong clinical knowledge and nursing assessment skills * Knowledge of long-term condition management * Knowledge of frailty, complex care and proactive care approaches * Knowledge of safeguarding legislation, processes and referral pathways * Understanding of the Mental Capacity Act and Best Interest decision-making * Knowledge of health promotion, prevention and personalised care planning * Knowledge of digital healthcare systems and electronic patient records * Knowledge of local community services and referral pathways Experience * Experience working in community, primary care, elderly care or long-term condition management * Experience working with frail, housebound or vulnerable patient groups * Significant experience of independently managing a complex caseload in a community, primary care or integrated care setting. * Experience of multidisciplinary team working * Experience supporting patients with complex health needs and multiple long-term conditions * Experience of autonomous clinical decision-making. * Experience assessing and managing patients with complex, long-term and multiple healthcare needs. * Experience within General Practice or Primary Care Network services * Experience using SystmOne Qualifications * Registered Nurse (NMC) * Community Specialist Practitioner qualification (District Nursing) or equivalent experience * Evidence of ongoing Continuing Professional Development (CPD) * Mentorship, teaching or assessor qualification Skills * Excellent verbal and written communication skills * Ability to communicate effectively with patients, carers, colleagues and partner organisations * Ability to work independently and manage workload effectively * Ability to manage and prioritise an allocated caseload * Ability to recognise clinical deterioration and escalate appropriately * Ability to recognise and escalate safeguarding concerns appropriately * Ability to develop positive professional relationships * Strong organisational and time management skills * Digital competency including Microsoft Outlook, Teams, Word and Excel * Competent use of electronic patient records and digital healthcare systems * Competent use of SystmOne and Accurx or willingness to undertake training * Ability to accurately document, monitor and report patient information * Experience supporting or supervising colleagues and learners 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. 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