PCN Ageing Well Nurse Practitioner

Integrated Care System; Havant; On-site; GBP 30,000 - 40,000; Full time

Job summary

A local healthcare network seeks an Ageing Well Nurse Practitioner to support patients in the Havant area. The role involves managing long-term conditions, collaborating with multidisciplinary teams, and promoting patient independence. Ideal candidates will have a nursing degree, NMC registration, and substantial experience in primary or community care. Competitive salary based on experience.

Qualifications

• Two years recent primary or community nursing experience required.
• Must have experience working with elderly or vulnerable people.
• Knowledge of national standards that inform practice.

Responsibilities

• Plan, implement and evaluate care for patients in the community.
• Manage long-term conditions and ensure safe, appropriate care.
• Facilitate patient education and self-management.

Skills

Clinical judgment

Teamwork

Communication

Autonomous decision-making

Culturally sensitive service

Education

Relevant nursing or health degree

Current UK NMC registration

Tools

EMIS systems

MS Office

Job description

Go back Havant and Waterlooville Primary Care Network

PCN Ageing Well Nurse Practitioner

The closing date is 25 August 2025

TheAgeing Well Nurse will work within their professional scope of practice in ageneral practice environment as part of our Primary Care Network (PCN). The PCNis made up of 5 member Practices and serves approximately 69,000 patients.

Asa key member of a multidisciplinary team, they will play a key role inpreventing avoidable hospital admissions. They will case-manage patients withfrailty and long-term conditions, promoting independence and supportingindividuals to live well in their own homes.

Main duties of the job

The Ageing Well Nurse Practitioner will plan, implement and evaluate care for patients in our community, to meet patients' needs and preferences in the delivery of high-quality health care. Ensuring that the patient's needs and preferences are known and communicated at the right time to the right people, and that this information is used to guide the delivery of safe, appropriate, and effective care.

In this fast-paced and rewarding role, they will be expected to work independently, exercising sound clinical judgment within the boundaries of their professional practice. They will also demonstrate a solid understanding of community services and collaborate effectively with the wider multidisciplinary team for guidance and support when needed.

About us

Our PCN is made up of 5 practices in the Havant and Waterlooville area. Working under the guidance of the Ageing Well Lead Nurse and GP, the Ageing Well Nurse Practitioner will receive daily support from the Social Prescriber, Care Coordinator, Acute Visiting Team, Clinical Pharmacists, and the wider practice team - including GPs and nursing staff.

Job responsibilities

• Undertakeclinical nursing practice using expert knowledge and clinical skills to deliverholistic care to patients living in their own home or care home.
• Collaborateclosely with GPs and work independently to deliver safe, effective care tofrail and housebound individuals, including those residing in care homes.
• Supportall members of the Ageing Well team, providing guidance when necessary,conducting supervision and appraisals as required.
• Initiateand interpret tests and investigations within scope of practice.
• Administerand provide medications / treatments according to protocol and Patient GroupDirections.
• Prescribe/supplymedications (as appropriate) following policy, patient group directives andlocal pathways.
• Promote/ support health & wellbeing, helping patients to remain independent andwell at home.
• Facilitatepatient education, self-management of disease, and behaviour modification tohelp reduce health inequalities.
• Conductthorough person-centred needs assessment to develop care plans for each patientin a timely manner.
• Maintainand regularly update a comprehensive register of frail patients, utilisingclinical frailty scoring tools to assess and monitor levels of frailty.
• Initiatethe process of diagnosis with patients suspected to have a chronic diseasee.g., diabetes, COPD, asthma, IHD referring to other clinical staff asappropriate.
• Proactivelymanage long term conditions alongside practice teams.
• Accuratelyupdate patient records on EMIS systems. All documentation must be timely,relevant, and clearly reflect the care provided.
• Directlyadmit patients to secondary care hospital in acute medical need.
• Promoteclear communication with the health care team and support medicationmanagement.
• Communicateeffectively with other healthcare professionals and make appropriate referralsto ensure coordinated, multidisciplinary care.
• Buildand communicate therapeutic working relationships with a wide array ofstatutory and voluntary organisations for the benefit of patient care andfacilitates good working relationships.
• Organiseand chair multidisciplinary team (MDT) meetings, fostering effective workingrelationships with health, social care, and third-sector partners to ensure aseamless, integrated response for patients with complex needs or long-termconditions.
• Workflexibly across various healthcare settings, including surgeries, home visits,and community.
• Activelyparticipate in clinical, PCN and practice meetings.
• Participatein team meetings, audits, and data collection for improving patient care.
• SupportSocial Prescribers / Care Coordinators in delivering high-quality care to frailand housebound patients.
• Provideexpert clinical advice and support to patients, carers, and colleagues,maintaining high standards of professional practice and clinical excellence.
• Operatein line with clinical protocols and guidelines, ensuring professional,compassionate support for patients, families, and carers - using resourcesresponsibly and efficiently.
• Contributeto service development through population health management tools by creatingand implementing innovative models, methods, and practices to enhance primarycare services for the frail population.
• Ensurecompliance with practice CQC requirements and maintain accurate documentation.
• Workwithin all relevant PCN practice policies and procedural guidelines e.g.,infection control, chaperoning, risk management.
• Contributeto PCN practice targets both local and national
• Developown knowledge and practice to meet objectives/changes in service, throughattendance on study days, self-directed learning, and reflection on practice.
• Participatein our appraisal system, matching organisational aims with individual objectives.
• Undertakeall mandatory training required for the role.
• Maintainthe highest standards of conduct and integrity

Duties will vary from time to time under thedirection of the post holders manager, the network manager and the networkclinical directors, dependent on current and evolving workload and staffinglevels.

Person Specification

Knowledge and Skills

• Understanding of Personalised Care
• Understanding of the wider determinants of health
• Knowledge of how the NHS works, including primary care and PCNs
• Ability to recognise/work within limits of competence, seeking advice if needed
• Understanding of the needs of older people / adults with disabilities / long term conditions particularly in relation to promoting their independence
• Basic knowledge of long-term conditions and associated complexities: medical, physical, emotional and social
• Clear, polite telephone manner
• Good interpersonal skills
• Ability to record accurate clinical notes
• Proficient in MS Office and web-based services

Personal Qualities

• Teamwork: Work effectively and professionally within the Ageing Well Team through willingness to proactively support and assist peers and colleagues.
• Autonomous: Ability to work independently by making informed decisions based on professional knowledge and clinical judgement
• Ability to actively listen, empathise with people and provide personalised support in a non-judgemental way.
• Ability to provide a culturally sensitive service supporting people from all backgrounds and communities, respecting lifestyles and diversity
• Solution Focussed: Ability to react to and face challenges or setbacks in a positive manner with a commitment to continuous improvement
• Commitment to reducing health inequalities and proactively working to reach people from diverse communities
• Ability to support people in a way that inspires trust and confidence, motivating others to reach their potential
• Ability to communicate effectively, both verbally and in writing, with people, their families, carers, partner agencies and stakeholders
• Ability to provide motivational coaching to support peoples behaviour change
• Ability to identify risk and assess / manage risk when working with individuals
• Strong awareness and understanding of when necessary to refer people to other
• health professionals, when the need is beyond the scope of the Ageing Well Nurse Practitioner Role.
• Ability to maintain effective working relationships and promote collaboration
• Personal accountability, emotional resilience, ability to work well under pressure
• Ability to organise, plan and prioritise on own initiative, including when under pressure and meeting deadlines
• Ability to work flexibly and enthusiastically within a team or on own initiative
• Knowledge of and ability to work to policies & procedures, e.g. confidentiality, safeguarding, lone working, information governance, and health and safety
• Demonstrable commitment to professional and personal development

Other Requirements

• Meets an enhanced Disclosure and Barring Service (DBS) check
• Access to own transport and ability to travel across the locality on a regular basis, including to visit people in their own home

Experience

• Two years recent primary or community nursing experience
• Knowledge of national standards that inform practice (NSF, NICE Guidelines)
• Experience of working in health, social care and other support roles in direct contact with people, families or carers (in a paid or voluntary capacity)
• Experience of working within multi - professional team environments
• Experience of supporting people, their families and carers in a related role
• Experience of working with elderly or vulnerable people, complying with best practice and relevant legislation
• Experience or training in personalised care and support planning
• Experience of data collection and using tools to measure the impact of services
• An appreciation of the new NHS landscape including the relationships between individual practices, PCNs and the commissioners

Qualifications

• Current UK NMC registration and maintains revalidation
• Relevant nursing or health degree
• History Taking and Physical Assessment
• Experienced and up to date in blood pressure, temperature, pulse, testing blood sugars, O2 sats, tissue/skin health, diabetic foot checks
• Up to date vaccinations and immunisations training for Covid/Influenza
• Evidence of continual professional development
• Full UK Driving Licence

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.

Havant and Waterlooville Primary Care Network

Depending on experienceBand 7 - Dependent on experience