The Community Complex Care Nurse will play a key role within Taunton Central PCN, identifying and working with patients who would benefit from proactive care, including but not limited to: patients living with moderate or severe frailty, or likely to become frail in next 10 years; patients experiencing health inequalities; and / or patients relying on unplanned care to manage their conditions Where integrated community-based services could better support those patients to manage their: physical and mental health needs; social care needs; and self-care. Supported by a multi-disciplinary team, the Community Complex Care Nurse will have day-to-day responsibility for ensuring PCN patients - who have been identified as appropriate for receiving the proactive model of care, and allocated to them - receive: An holistic assessment to identify the patients health, social and self-care needs and goals; Personalised care and support planning, to include but not limited to: collation of personalised, baseline and goals information. preparation of a Personalised Care and Support Plan (PCSP); that plan to be regularly reviewed, updated and implemented to meet the patients changing needs and goals; and subject to relevant training, preparation of a Treatment Escalation Plan (TEP), if appropriate for the patient; Multidisciplinary working to address and meet the patients needs and goals, to include support to navigate the care and support available to them across local health and care services; Co-ordinated care, to include but not limited to: the promotion of self-care; and supporting patients to access the services and support they require to understand and manage their own health and wellbeing (e.g. making referrals village agents/social prescribing link workers, health and wellbeing coaches, and other professionals as and when appropriate); Intervention and support at a level appropriate to their need and as identified as part of their holistic assessment, personalised care and support planning and multidisciplinary working. The post-holder will work closely with patients usual GPs, surgeries and the PCNs health care teams, to manage a caseload of patients. They will act as the single point of contact for those teams, and external health and social care providers, to ensure the appropriate support is made available to their caseload of patients and their carers; supporting the patients to understand and manage their condition and ensuring their changing needs are addressed. This is achieved by bringing together all the information about a persons care and support needs and exploring options to meet these within a single personalised care and support plan, based on what matters to the person and through multidisciplinary and coordinated working, to include self-management of needs by the patient at home. The post-holder will be a dedicated, reliable and patient-focused healthcare professional. They will enjoy working with a wide range of people, delivering personalised care and the challenge, and rewards, of setting up and developing new services. They will have excellent written and verbal communication skills, adopt a holistic and personalised approach to care delivery, and have good organisational and time management skills. They will be highly motivated, with a flexible attitude; be able to work independently, whilst committed to work and learn as part of a team. Above all, they will be dedicated to providing patients, their families, and carers with proactive, joined-up and personalised care. This role is intended to become an integral part of the PCNs multidisciplinary team, which works alongside local village agents/social prescribing link workers, other community health care teams, social care teams and secondary care teams to provide a system-wide approach to personalised care. The post-holder will be required to promote and embed a personalised care approach across the PCN and contribute to the development of a local integrated neighbourhood team (INT). The role is a senior clinical role within the PCN. Supported by the GP Clinical Lead for the Proactive Care Team and the Lead Nurses of the five PCN GP surgeries, the postholder will be required to provide day-to-day clinical supervision of, and clinical leadership for, the PCNs Community Health Care Assistant. The post-holder may also be required to be allocated as Lead Practitioner for some parts of the Proactive Care Teams service(s) as the team, and its workstreams develop. The job description and person specification may be reviewed on an ongoing basis in accordance with the changing needs of Taunton Central Primary Care Network and its GP member practices.