Pro-active Care Nurse

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

Job summary

A regional healthcare organization in Southampton is seeking a registered nurse to manage patients' health in the community. The role involves working autonomously to assess patients, develop care plans, and collaborate with healthcare teams to prevent hospital admissions. Ideal candidates possess strong clinical judgment, must have a nursing degree, and demonstrate key skills in patient assessment and communication. The position supports continuous professional development within a dynamic community healthcare setting.

Qualifications

• Significant experience in primary care is mandatory.
• Experience in a community setting is essential.
• Evidence of continuous professional development is required.

Responsibilities

• Support patients with long-term conditions and vaccination programs.
• Establish treatment and care plans.
• Liaise across primary, secondary, and tertiary care services.

Skills

Autonomy in clinical practice

Patient risk assessment

Empathy and communication

Education

Registered nurse with NMC registration

Teaching/mentorship qualification

Tools

Microsoft Office

Job description

This role is to identifyvulnerable patients and those at high risk of hospital admission in the community. The postholder will be able to demonstrate safe and sensitive clinical judgement indiffering contexts, with a variety of individuals and groups and within theirown scope of clinical competency. Although practice-based, there will be stronglinks and close working arrangements in place with the community care team, theintegrated care team, as well as secondary care when needed, participating inMDT meetings with the multi-disciplinary team, to feedback on cases.

Main duties of the job

The post holder will work with primary care network staff, community teams and our existing care navigator team to ensure that well-being plans are completed andrecorded onto the clinical system alongside the Frailty Team over a 7-dayperiod.

The post holder will berequired to work with a high degree of autonomy and professional accountability,a primary aim of the role is to prevent unnecessary hospital admission ofpatients.

About us

Eastleigh Southern Parishes Network Ltd. is afederation of 3 local practices including, Blackthorn Health Centre and HedgeEnd Surgery & Living Well Partnership, who are working together to shareresources, skills & experience to provide cost effective, patient-centeredhealth care for all patients in the Eastleigh Southern Parishes area.

We aim to develop accessible and high qualityhealth services to people in Eastleigh Southern Parishes whilst supportingGeneral practice and the NHS through collaboration with Commissioners and otherproviders of Health and Social Care.

Job responsibilities

Thisrole will provide support to patients in the community with long termconditions such as diabetes, chronicrespiratory disease, chronic pain etc. and will require some clinical activitythrough supporting practices with the vaccination programme for house boundpatients, working as part of the practices extended team.

Establish treatment and care plans thatanticipate clinical changes, deterioration or escalation of need. Plans mayinclude decisions around end of life; preferred place of care, preferred placeof death and cardio-pulmonary resuscitation.

Make clinical decisions for patients on thecaseload with GP support.

Promote the understanding and use ofstandardised monitoring and predictive tools, investigations and techniques.

Support carers and develop personalisedapproaches to care. Work with patients on self-management strategies. Supportcarers and patients to have confidence and competence to self-test and monitorand be proactive on known triggers to ill-health.

Promote the appropriate use of prescribed andover the counter medications, homely remedies, wound care and nutritionalproducts. Take appropriate urgent action where the risk of harm is identifiedand initiate alerts to appropriate agencies where non-clinical risk issuspected or identified. Liaise with pharmacists/specialist community elderlycare pharmacist on the appropriate documentation, information, packaging andlabelling of medication to support self-management and reduce risk.

Liaise and provide support on the management ofpatients across primary, secondary and tertiary care services. Identifystrategies to avoid unnecessary, multiple or missed attendance at hospitalappointments. Signpost patients to access appropriate dental, optical and nailcutting services.

Leadership

Supporting the primary care network teams,having a flexible approach to managing the day to day priorities of theirworkload and support the objectives of the team as a whole.

Performance and attitude to reflect theprinciples of the professional code of conduct and be commensurate to the roleas a clinical practitioner.

Support the development and review of policiesfor the clinical team, procedures, supporting with audits and strategies toensure progress in the delivery and outcomes of the project.

Develop communication links and maintain goodworking relationships within the primary care network team and externalagencies.

Advocate for patients in situations whereconcerns about care or professional conflict arise. Use appropriate avenues ofreporting and escalate concerns in a timely fashion. Adhere to safeguardingpolicies.

Education and Development

To develop and maintain own clinical practice,identify clinical supervision needs and participate in mandatory training andappraisals.

Support the educational, training andprofessional development of colleagues.

To advise the clinical team and organisation onlearning needs that arise through clinical practice, outcomes of audits,contacts within the project.

To maintain a willingness to explore andundertake new and different ways of working that offer improvements topractice, service delivery or clinical outcomes for patients.

Participate in link and educational events withother organisations aiming to promote same or similar outcomes.

Positively promote the aims of the project toother professional organisations, to patients and the public.

Information Governance

Maintain accurate and appropriate recording ofconfidential and sensitive information.

Ensure consistency of information held acrossdifferent media.

Maintain the security and integrity ofinformation held electronically or in paper format.

Ensure written or verbal consent is sought whereinformation needs to be shared outside of agreed networks.

Ensure clinical investigations, results, theirinterpretation and treatment options are discussed and documented appropriatelywithin the team and with appropriate external agencies.

Confirm and support the role of all patientdesignated legal health advocates.

Communicate the rationale for determining thelevel of urgency of interventions and where necessary, initiate onward referralto appropriate agencies.

Service Development

Identify processes that identify prevention ofhospital admissions/ other savings for future project funding

Identify developing themes and trends that sitoutside of the current project and may require consideration for inclusion inlater service level agreements.

Identify and advise on reduced or redundantactivity to be reviewed or excluded in later planning arrangements.

Identify risks to the project arising fromunknown or unforeseen situations in the locality or within the client group.

Identify equipment, skills or further learningto support the future success of the project.

Person Specification

Experience

• Significant experience working within primary care, ability to assess and manage patient risk effectively and safely.
• Evidence of continuous professional development.
• Competent in Microsoft Office.
• Experience of working in a community setting.

Qualifications

• Registered nurse with current NMC registration/degree qualified
• Teaching/mentorship qualification evidence of teaching ability.
• Previous experience in a team leader role.

Personal Qualities and Attributes

• Able to work autonomously, understanding the importance of working in a team.
• Ability to listen, empathise with people and provide person centred support in a non-judgemental way.
• Professional role model.
• Works within agreed scope of the primary care network seeking advice of colleagues.
• Can undertake research and audits, applying to practice.
• Driving license essential and ability to travel across the locality.
• Experience of quality improvement.

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.