Chronic Disease Practice Nurse
Job Description
Job summary
Note interview date will likely be Monday 12th May 2025
Role Summary
An exciting opportunity has arisen for an experienced and dedicated Practice Nurse to join our innovative and forward-thinking Primary Care Network (PCN).
Based at our busy Community Investigation Hub at Abbey Manor Medical Centre, this role offers the chance to deliver high-quality chronic disease management clinics on behalf of all practices in Yeovil.
We are proud to be a dynamic PCN that embraces innovative models of care, including group chronic disease clinics aimed at enhancing patient outcomes and engagement.
The successful candidate will also provide valuable support to the PCN Clinical Lead in the day-to-day running of the Community Investigation Hub, adult vaccination programmes throughout the year, and chronic disease reviews in care homes and patients own homes.
This is a fantastic opportunity for an enthusiastic and motivated nurse who is passionate about chronic disease management and keen to be part of an exciting and evolving healthcare environment.
PCN's core business hours are Monday through Friday, 0830 - 1630.
Main duties of the job
Your responsibilities will include:
- Deliver high-quality chronic disease management clinics, supporting the practices within Yeovil to achieve QOF, DES, and other clinical targets for conditions including COPD, Asthma, Heart Failure, and Diabetes.
- Take a leading role in delivering innovative group chronic disease clinics to enhance patient care and engagement.
- Provide expert advice and support to patients, including medication reviews and lifestyle advice.
- Support the delivery of adult vaccination programmes throughout the year, including flu and COVID-19 vaccinations.
- Provide chronic disease reviews within care homes and patients own homes as required.
- Apply infection control measures in line with local and national guidelines.
- Maintain accurate and comprehensive patient records on EMIS in accordance with NMC guidelines.
- Work in accordance with PGDs and support HCAs working to PSDs for vaccination delivery.
- Collaborate effectively with other members of the primary healthcare team.
- Maintain and update standard operating procedures (SOPs) and policies within own area of work.
- Provide cover for colleagues as required and coordinate with the PCN Manager to address any staffing shortages.
About us
The Yeovil Primary Care Network (PCN) is an exciting and creative place to work.
Yeovil PCN was founded in 2019 and has continued to improve and enhance the services it provides to its community.
We are a cooperation of five GP practices in Yeovil and a central PCN Hub team situated at Abbey Manor Medical Centre, and we aspire to provide clinical excellence and proactive patient-centered care.
Our successful services currently include a thriving Community Investigation Hub, the County's top performing covid and flu vaccination programme, our supportive and engaging Care Home and Proactive Care team, our highly regarded Physiotherapy team and the NHS Health Check Service, which we were recently awarded.
We also have fresh and interesting initiatives in the works, and we think that our employees are the primary drivers of innovation and delivery, therefore we invest in their training and development.
We are committed to strengthening our connections with community services and other system partners in order to overcome obstacles and establish an Integrated Neighbourhood Team that will enable us to deliver significant patient-centered care. Yeovil is a charming rural town situated on the border of Somerset and Dorset. There are lots of family-friendly nearby amenities and excellent transport options.
Staff also benefit from the NHS Pension Scheme, Blue Light Card and other discount opportunities and competitive annual leave and bank holiday entitlement.
Job responsibilities
Responsibilities
Your responsibilities will include:
- Deliver high-quality chronic disease management clinics, supporting the practices within Yeovil to achieve QOF, DES, and other clinical targets for conditions including COPD, Asthma, Heart Failure, and Diabetes.
- Take a leading role in delivering innovative group chronic disease clinics to enhance patient care and engagement.
- Provide expert advice and support to patients, including medication reviews and lifestyle advice.
- Support the delivery of adult vaccination programmes throughout the year, including flu and COVID-19 vaccinations.
- Provide chronic disease reviews within care homes and patients own homes as required.
- Apply infection control measures in line with local and national guidelines.
- Maintain accurate and comprehensive patient records on EMIS in accordance with NMC guidelines.
- Work in accordance with PGDs and support HCAs working to PSDs for vaccination delivery.
- Collaborate effectively with other members of the primary healthcare team.
- Maintain and update standard operating procedures (SOPs) and policies within own area of work.
- Provide cover for colleagues as required and coordinate with the PCN Manager to address any staffing shortages.
Communication
- Utilise and demonstrate sensitive communication styles, to ensure patients are fully informed and consent to treatment
- Communicate with and support patients and their families who are receiving bad news
- Communicate effectively with patients and carers, recognising the need for alternative methods of communication to overcome different levels of understanding, cultural background and preferred ways of communicating
- Anticipate barriers to communication and take action to improve communication
- Maintain effective communication within the PCN environment and with external stakeholders
- Act as an advocate for patients and colleagues
- Ensure awareness of sources of support and guidance and provide information in an acceptable format to all patients, recognising any difficulties and referring where appropriate
Delivering a quality service
- Recognise and work within own competence and professional code of conduct as regulated by the NMC
- Produce accurate, contemporaneous and complete records of patient consultation, consistent with legislation, policies and procedures
- Prioritise, organise and manage own workload in a manner that maintains and promotes quality
- Deliver care according to NSF, NICE guidelines and evidence-based care
- Assess effectiveness of care delivery through self and peer review, benchmarking and formal evaluation
- Initiate and participate in the maintenance of quality governance systems and processes across the organisation and its activities
- In partnership with other clinical teams, collaborate on improving the quality of health care responding to local and national policies and initiatives as appropriate
- Evaluate patients response to health care provision and the effectiveness of care
- Support and participate in shared learning across the PCN and wider organisation
- Understand and apply legal issues that support the identification of vulnerable and abused children and adults, and be aware of statutory child/vulnerable patients health procedures and local guidance
- Working with PCN management to ensure the whole team have skills and knowledge regarding domestic violence, vulnerable adults, substance abuse and addictive behaviour. Provide guidance and support to ensure appropriate referral if required
Leadership personal and people development
- Take responsibility for own learning and performance including participating in clinical supervision and acting as a positive role model
- Support staff development in order to maximise potential
- Enlist support and influence stakeholders and decision-makers in order to bring about new developments in the provision of services
- Contribute to the development of local guidelines, protocols and standards
- Maintain active involvement in the planning and processes of PCN commissioning or similar initiatives
Team working
- Work as an effective and responsible team member, supporting others and exploring the mechanisms to develop new ways of working
- Delegate clearly and appropriately, adopting the principles of safe practice and assessment of competence
- Create clear referral mechanisms to meet patient need
- Prioritise own workload and ensure effective time-management strategies are embedded within the culture of the team
- Work effectively with others to clearly define values, direction and policies impacting upon care delivery
- Work ...
