JOB PURPOSE AND DESCRIPTION To work with colleagues within the multi-disciplinary team to provide high quality, evidence based care appropriate to the patient's needs. To provide assessment, screening and treatment services which are relevant to the patients and their families with emphasis on improving diet and exercise routines whilst actively discouraging cigarette smoking and alcohol abuse through health promotion clinics. To work within the community undertaking the holistic review of older and frail patients, including: 1. Social situation 2. Mobility 3. Long term condition management 4. Immunisations 5. Diet and nutrition 6. Living arrangements and transportation 7. Screening for dementia where applicable Develop a relationship of trust with the patients who after assessment are identified as being someone for whom case management would be beneficial, liaising with other bodies, such as carers, safeguarding colleagues, social services and other parties to support the meeting of identified needs. Support patients to assist themselves in accessing care and support where appropriate. Work in partnership with our Advanced Nurse Practitioner for Older People and with the patient's usual GP to ensure seamless care, undertaking tasks to support the ongoing case management of patient's. In a timely fashion to identify and review discharge information relating to older patient's whose admission to secondary care was unplanned, contacting patient's in order to ensure sufficient support is available to meet their post-discharge needs. In line with personal competencies undertake the assessment, review and treatment of patient's, recording care according to the practice requirements and referring on where necessary. This could be routine nursing skills, such as wound assessment, and for those with enhanced training this could include examination techniques. To adhere to the practice's policies, protocols and guidelines, including appropriate use of resources and referral to colleagues and other services as required. Contribute to and undertake own clinical audit, supporting quality improvement and evidencing practice service standards. Participate in clinical supervision and manual appraisal, and the development of annual Personal Development Plans. Attendance at mandatory training and maintain professional development by attending clinical supervision, courses and study days. To advocate for patients when necessary. To be confident in your knowledge about local safeguarding procedures, reporting safeguarding concerns through appropriate channels in a timely fashion where appropriate. Participation in annual flu clinics (some of which will require working additional hours) To feed into the development of protocols and guidelines for use in the Practice and liaise with the management team to give advice on the appropriate use of time, recall and appointment systems and resource development. Attendance at monthly nurse meetings, regular education meetings and working group meetings which focus on the quality and development of the service. To contribute to the teaching of medical students, GP registrars and Community nurses in training. To participate in the administrative and professional responsibilities of the practice team and to contribute to the formulation of practice philosophy, strategy and policy. To maintain confidentiality and follow information governance good practice. To report "near misses", incidents and significant events in line with practice policy and procedures, to participate in significant event analysis to aid the learning for the organisation and individuals from such events and to follow the practice's 'whistleblowing' policy should the need occur. Members of the nursing team must retain their NMC license to practice, achieve revalidation when required and work in accordance with the NMC code of professional conduct. MOST CHALLENGING/DIFFICULT PARTS OF THE JOB To make evidence based decisions whilst implementing care appropriate to the patient's needs within the resources available within the practice and the wider NHS and social care system. Prioritising a varied and demanding workload on a daily basis to meet deadlines/performance indicators. To manage the risk in patient care, balancing patient's wishes and preferences against patient safety, recognising that for older, vulnerable patient's there is a greater level of risk than is usual. Keeping up to date, enhancing the provision of service from the Nursing Team in line with practice strategic priorities. Responding appropiately to complex situations, ethical dilemmas and emergencies. COMMUNICATIONS AND RELATIONSHIPS Nurses will regularly communicate with various people through face-to-face or via the telephone/e-mail Key relationships 1. General Practitioners 2. Practice Manager 3. Nurse Manager 4. Other members of the Nursing Team 5. District Nurses 6. Social Services and other social care providers 7. Clerical/admin staff PHYSICAL, MENTAL, EMOTIONAL AND ENVIROMENTAL DEMANDS OF THE JOB Pertinent to roles undertaken with the Practice - skills undertaken will vary between practitioner These are dependent on role, but could include Principle Physical Skills: 1. Supporting patients 2. Wound care 3. Holistic Assessment Physical Demands: 1. Sitting 2. Walking 3. Standing 4. Driving to visit patients in the community 5. Light and moderate physical effort. The dressing of wounds and particularly leg ulcers, can be physically taxing. Mental Demands: 1. Applying physical skills to Practice 2. Scheduling visits, working to time 3. Attending and contributing to case conferences 4. Record keeping as per NMC code 5. Inputting data 6. Analysing assessment data Emotional Demands: 1. Care of terminally ill 2. Being required to manage a large workload and prioritise accordingly Working Conditions: 1. Exposure to body fluids 2. Infectious materials 3. Sharps 4. Challenging behaviours