Practice Nurse - Kingsway Surgery

The Registered Nurse appointed will be responsible for providing a domiciliary and practiced based care in the City Health area for the coordination, management and monitoring of the care of housebound patients with long-term chronic illness (for example heart disease, COPD and diabetes).

Through a structured programme of monitoring the primary focus of this role will be on service quality, through specialist assessments and reviews of health care needs, the optimisation of care where co-morbidity exists, maximising wellbeing, self-empowerment, and quality of life.

The Chronic Conditions nurse will be an expert generalist whose role will involve providing advanced chronic disease management care in the community setting. The post holder will work autonomously in patients homes and in primary care premises, to co-ordinate the care needs of those patients on the caseload.

The Chronic Conditions Nurse will work in collaboration with partner organisations and other professionals to ensure patients health care needs are met appropriately and hospital admissions are reduced.

The Chronic Conditions Nurse will:

Assess patients, plan and implement care, provide specialist advice to both patients and healthcare colleagues and act as a resource for other community nurses.

Maintain comprehensive and contemporaneous records for each patient in line with SBUHB, NMC and local policy, liaising closely with the patients GP and the Practices own specialist nurses where needed.

Undertake relevant Risk Assessments associated with this role and working environments as indicated in the SBUHB Health and Safety Policies and Risk Management Strategy, and act on any findings in a timely manner.

Undertake an initial patient assessment including the taking of a comprehensive history, perform a comprehensive and systematic physical examination and establish baseline data to inform the development of a specialised, individual and comprehensive care plan.

Consider signs and symptoms, direct patient tests, laboratory tests results, and other measures to function when reviewing the condition of the patient.

Collaborate across the wider team to plan and implement treatment for acute illness/injury/chronic illness as required.

Monitor indicators of chronic disease, anticipating possible decline and proactively managing this to enhance well-being, and to maintain independence.

Undertake minor illness clinics within cluster practices within own scope of practice.

Be accountable for own professional actions; not directly supervised.

The practice has been established since 1870 and had multiple locations over the years to adapt to growing demand before finding a place on the Kingsway in 1993 with its own parking facilities underneath. The practice benefits from a stable and consistent team across clinical and non-clinical roles. Each GP has a lead role to play in the practice which assists in the success of the practice achieving excellent QAIF standards and access standards.

The Kingsway Surgery will act as the base for this role but they will serve all 8 practices in the City Cluster. The City Health Cluster Network has agreed to deploy funding to address potential health inequalities amongst housebound patients and those with limited mobility/support living in the Network area through improving access to nurse-led chronic disease monitoring in the patients home.

The Chronic Conditions Nurse role will be attached to City Health Cluster Network to lead this Chronic Conditions housebound service for Cluster wide patients.

Care Co-ordination

Integrate care across all care settings, preventing duplication, fragmentation and delay occurring as patients move between care settings.

Build relationships across professional and organisational boundaries, breaking down barriers and smoothing the patient journey.

Work with other Health Care Professionals to monitor, manage and treat Chronic Conditions, including non-drug based treatment methods, utilising robust management plans in line with national and local policies and patient needs.

Assess, plan, implement and evaluate individual treatment plans for patients with Chronic Conditions and working collaboratively with practices within the designated cluster to maintain quality patient care for housebound patients.

Review medication for therapeutic effectiveness within your scope of practice and in collaboration with a GP or non-medical prescriber. Ensure national and local policies are adhered to when devising or amending treatment plans.

Assist in planning, co-ordinating and supervising the workload of junior nursing staff and HCSWs associated with the Chronic Conditions Management service.

Participate as a key member of the multidisciplinary team through development of collaborative and innovative practice.

Communication

Be able to communicate effectively will all patients, colleagues and associated stakeholders, and support and encourage patient/carer interventions and…