Long-Term Conditions Registered Nurse

The Methodist Church in Britain; Belper CP; Presencial; GBP 32.000 - 42.000; Jornada completa

Descripción de la vacante

The Methodist Church in Britain advertises a community nursing role based in Belper PCN Home Visiting Service. You will manage a caseload of adults with long-term conditions, conducting home visits and care planning in collaboration with GPs and a neighbourhood team.

Responsibilities include holistic assessments, monitoring, medicines reconciliation, health promotion and coordinated care across primary care, social care and community services.

Formación

• Evidence of continuing professional development.
• Prepared to complete all mandatory training.

Responsabilidades

• Manage an agreed caseload of adults with long-term conditions, prioritising those at risk of deterioration.
• Undertake holistic assessments in patients' homes and care homes.
• Complete long-term condition reviews under NICE guidance and local pathways.
• Develop, implement and evaluate personalised care plans with patients and carers.
• Record accurate information in the shared electronic patient record.
• Provide education and coaching to patients and carers on long-term condition management.

Conocimientos

Holistic assessment

Care planning

Multidisciplinary teamwork

Communication

Independent working

Educación

NMC registration as a registered nurse

Descripción del empleo

Belper PCN's Home Visiting Service seeks a registered nurse to manage a caseload of adults with long-term conditions. The work centres on assessing, planning and reviewing care for people who are housebound, frail or have complex needs, in their own homes and care homes. Travel across the PCN area is central, with the post working alongside GPs and a wider neighbourhood team, and hours of 37.5 or 30 a week offered. Current NMC registration and an Enhanced DBS check are required before appointment.

What the job involves

• Manage an agreed caseload and waiting list of adults with long-term conditions, prioritising those at risk of deterioration, avoidable admission or health inequality
• Undertake holistic assessments in patients' homes and care homes covering physical and mental health, frailty, medicines, nutrition, falls risk, social circumstances, carer needs and safeguarding
• Complete structured long-term condition reviews within competence, such as diabetes, cardiovascular disease, hypertension, respiratory disease and frailty, under NICE guidance and local pathways
• Develop, implement and evaluate personalised care plans with patients, carers and professionals, including advance care planning where appropriate
• Recognise deterioration, start immediate care within scope of practice and escal…
• Undertake and interpret clinical observations and point-of-care or diagnostic tests within competence and service protocols
• Support medicines optimisation through reconciliation, adherence review, side-effect monitoring and referral to a GP, pharmacist or independent prescriber
• Deliver immunisation, health promotion, prevention and supported self-management where trained, authorised and clinically appropriate
• Make timely referrals and coordinate care across primary care, community services, pharmacy, mental health, social care, care homes and voluntary services
• Use PCN data, clinical registers and risk stratification to identify people who would benefit from proactive intervention
• Record accurate, contemporaneous and coded information in the shared electronic patient record
• Provide education and coaching to patients, carers, care-home staff and colleagues on long-term condition management and recognition of deterioration

What’s required

Qualifications

• Evidence of relevant continuing professional development
• Prepared to complete all required statutory and mandatory training

Registration & licences

• Current NMC registration as a registered nurse

Experience

• Post-registration experience managing adults with long-term conditions
• Experience of holistic assessment, care planning and multidisciplinary working
• Experience supporting people with complex needs

Skills & knowledge

• Knowledge of evidence-based long-term condition management, prevention and recognition of deterioration
• Understanding of consent, capacity, safeguarding, infection control, medicines safety, confidentiality and information governance
• Person-centred assessment, clinical observations, risk assessment, care planning and escalation within competence
• Clear communication, including explaining complex information and managing difficult conversations
• Ability to work independently, manage a community caseload and seek timely clinical support
• Competence with clinical IT, secure communication and using data to improve care

Checks & eligibility

• Enhanced DBS check and occupational health clearance
• Right to work
• Access to suitable transport for business use, subject to reasonable adjustments

Other

• Suitable for lone working, flexible and resilient

Nice to have

• Degree-level study or equivalent experience
• Recognised long-term condition, practice nursing, community nursing, frailty, case management or advanced assessment qualification
• Independent or supplementary prescribing qualification
• Primary care, community, home-visiting or care-home experience
• Management of multimorbidity, frailty or palliative needs
• Knowledge of local Derbyshire pathways, urgent community response and virtual wards
• Competence in diagnostics, spirometry, foot assessment, injectable therapies, vaccination or remote monitoring
• Experience coordinating complex care or leading multidisciplinary case management