Care Home Team Senior Clinician (Nurse)

Job summary

The post holder will operate as an Independent, self-motivated and autonomous practitioner within the Primary Care Network (PCN), delivering high-quality urgent and proactive care to residents within care home environments. The role requires a dynamic clinician who can seamlessly flex between rapid-response acute clinical assessments, scheduled work and proactive multi-disciplinary reviews.

Main duties of the job

Operating at an advanced level, you will manage complex caseloads advancing frailty, multi-morbidities, and palliative care. You will lead on service improvement, support clinical governance, staff training and mentor junior staff, fully aligning with the NHS Leadership Academy Framework and Band 7 competencies.

The post holder will work collaboratively with GP practices, community teams, secondary care providers and care home staff to improve outcomes for residents, reduce avoidable hospital admissions and facilitate care closer to home.

The applicant will require at least 3-5 years post registration experience, experience of implementing change in clinical practice and experience of clinical assessment and care planning.

About us

The Lytham St Annes Primary Care Network covers 5 GP Practices, Holland House, Fernbank, Parcliffe, Poplar, and Ansdell, serving a population of approximately 53,000 registered patients. The PCN serves a diverse population with relatively low deprivation with a complexity from an above average elderly population and above average residents in care homes.

The PCN has a large population that reside in Care/ Nursing Homes with approximately 36 homes across the footprint and 900+ residents.

Job responsibilities

Key Responsibilities

Advanced Clinical Practice & Acute Response

Main aspect of the role will be to support the practices and visit patients in Care Homes following agreed pathways with the GP Practices.

Provide rapid, autonomous assessment of acutely unwell care home residents, utilising advanced physical assessment and clinical history-taking skills as directed by the patients GP practice.

Autonomous Decision Making: Diagnose, formulate, and execute immediate treatment plans for patients presenting with complex, undifferentiated, or unstable conditions.

Prescribing & Medicine Management: Safely prescribe medications within individual scope of practice as an Independent Prescriber or work under Patient Group Directions (PGDs) where applicable, ensuring rigorous adherence to safety standards.

Admission Avoidance: Utilise expert clinical judgment to safely manage high-risk patients in their place of residence, coordinating with community assets to minimize unnecessary hospital admissions.

Work across boundaries and in partnership with primary and secondary care clinicians and social services, coordinating care promoting a multi-disciplinary approach.

To act as a point of contact, where appropriate for the care home staff when there is a request to see, treat or refer any patient whose health status has deteriorated.

To refer patients to the GP practice where appropriate.

Assess patient needs through effective planning, implement and evaluate care according to individualised patient needs. Ensure that all patient computer records are maintained correctly.

Recognise when patient presentation requires referral onto other health professional or specialist teams and take appropriate actions.

Act as a specialist clinical resource for care home staff regarding assessment, escalation and management of deteriorating residents.

Maintain accurate, timely and legally compliant clinical records using PCN and practice clinical systems.

Proactive Care & Care Home Team Integration

Proactive Holistic Reviews: The role will predominantly work on the acute response but will be expected to also provide pro-active care as part of the function such as participate in scheduled Multi-Disciplinary Team (MDT) reviews as required for care home residents to optimise health, manage frailty, and prevent future health deterioration. The postholder will be required to work closely with practices to manage patients care.

Personalised Care Planning: To develop individualised care management plans (PCSP for the patients in close discussion with them and their careers, care home staff and GPs.

Anticipatory Care & DNACPR: Initiate and facilitate sensitive, expert discussions regarding Advance Care Planning (ACP) forms with residents, families, and staff.

Workforce Flexibility: Dynamically pivot daily priorities between urgent acute requests and scheduled proactive reviews based on the immediate clinical demand of the PCN care home population.

The post holder will provide support for patients to remain in their own care setting, improving their health outcomes and quality of life. The role will provide clinical skills to patients and provide expert knowledge.

The role will support patients with end-of-life support, enabling them to die in their own care home if that is their wish.

Supporting the management of residents with multiple long-term conditions, dementia and complex health needs.

Leadership, Governance, & Service Development

Clinical Leadership: Act as a clinical role model and expert resource for care home staff, PCN colleagues, and the wider multidisciplinary team.

Quality Improvement (QI): Identify, design, and implement clinical audits and QI projects to enhance the quality, safety, and efficiency of care home services across the PCN.

Risk Management: Take a lead role in the investigation of clinical incidents, near-misses, and safeguarding concerns within care homes, ensuring lessons are learned and embedded into local practice.

Communicate sensitive/contentious and occasionally highly complex medicine related information and advice to patients, carers, GPs and other members of the health care team.

Communicate on a variety of different levels depending on whether you are dealing with health professionals or patients. Information may be complex and require translation into a more patient friendly format.

To be aware of the Data Protection Act to ensure appropriate action is taken to ensure patient confidentiality and protection of patient information.

Education & Training

Workforce Upskilling: Design and deliver evidence-based training sessions for care home staff on topics such as early signs of deterioration (e.g. RESTORE2), hydration, and falls prevention.

Mentorship: Supervise, mentor, and complete workplace-based assessments for junior clinical staff, students, or PCN colleagues.

Person specification

Experience

Essential

• Minimum 35 years post-registration experience, including significant time in acute, urgent, or community care.
• Experience working autonomously with frail older people with complex multi-morbidities.
• Demonstrable experience of multidisciplinary working across organisational boundaries.
• Experience working autonomously and managing clinical risk.
• Experience of Long-Term Conditions and a willingness to develop the skills further.

Desirable

• Experience working in care homes.
• Experience working within a Primary Care Network or General Practice setting.
• Experience leading service improvement, audit or quality improvement projects.
• Experience supervising or mentoring healthcare professionals

Qualifications

Essential

• Registered Clinician (Nurse) with valid NMC registration.
• Masters level module in advanced Physical Assessment & Clinical Reasoning (or equivalent portfolio evidence).
• Non-Medical Prescribing qualification (V300) supported by substantial prescribing experience.

Desirable

• Prescribing experience over 18 months with a comprehensive prescribing formulary.

Skills and Knowledge

Essential

• Expert clinical examination, diagnostic, and risk-management skills.
• EMIS Web proficiency.
• Ability to communicate complex, sensitive information to patients, families, and MDT partners.
• Confidence in using IT tools to aid communication and documentation such as Video Consultations.
• High-level adaptability to manage a fluctuating, dual-purpose workload
• Ability to communicate with other providers in a clear and professional manner.
• Ability to undertake holistic assessments incorporating physical, psychological and social factors.
• Sound knowledge of safeguarding, mental capacity and best interest frameworks.
• Ability to build relationships with the LSA practices to ensure good working communication.
• Full UK Driving Licence and access to transport.

Desirable

• Proficient in primary care clinical systems (e.g. EMIS Web)
• Knowledge of the NHS Network Contract DES requirements for care homes.