Job description

Job responsibilities

Clinical assessment and care delivery

Deliver dementia holistic health checks using agreed clinical templates within EMIS.

Undertake physical health assessments including blood pressure, pulse, body mass index (BMI), falls risk, Malnutrition Universal Screening Tool (MUST) nutrition screening, pain and continence.

Carry out Clinical Frailty Scale (CFS) reviews and accurately record findings.

Undertake blood pressure, weight, urinalysis, non-urgent ECG and other agreed investigations, and venepuncture where trained and assessed as competent.

Monitor and document mental health status, including mood, behaviour and signs of delirium, escalating concerns promptly.

Identify risks related to medication, adherence and side effects and escalate appropriately.

Undertake falls and continence assessments and contribute to risk stratification, prevention interventions and management plans.

Caseload management and care coordination

Manage a caseload of lower-risk frailty patients previously assessed by the PCN frailty team, with diary and appointment support provided by that team.

Provide follow-up visits for lower-risk frail patients as directed by the frailty team, supporting care planning, treatment compliance and review.

Support medication reviews by checking compliance, adherence and the patient's understanding of medication changes.

Chase and follow up clinical results, investigations, outstanding tasks and care plans.

Monitor and follow up equipment requests and orders to ensure timely provision, and confirm that recommended equipment or adaptations are in place.

Support patients to access services and interventions, helping to ensure appointments are attended and not missed.

Make appropriate onward referrals and connect patients to appropriate services, including social prescribing and Age UK.

Safeguarding, consent and mental capacity

Recognise and respond to safeguarding concerns for adults at risk, escalating and reporting in line with local safeguarding policy and the postholder's level of safeguarding training.

Apply the principles of the Mental Capacity Act 2005, obtaining and recording valid consent and, where a patient lacks capacity, supporting best interests decision making and recognising when Deprivation of Liberty Safeguards may apply.

Undertake carer wellbeing conversations, provide signposting, and remain alert to carer strain and safeguarding indicators.

Communication and relationships

Document personalised care discussions ('what matters to me') and support advance and anticipatory care planning within scope in conjunction with the Frailty Practitioner team.

Communicate sensitively and effectively with vulnerable adults, families and carers, adjusting communication to individual needs.

Participate in multidisciplinary team (MDT) discussions and contribute to care planning.

Cope with occasional exposure to distressing and emotional situations while maintaining professionalism, compassion and resilience.

Information, recording and reporting

Ensure accurate, contemporaneous and timely data recording and reporting in line with EMIS templates and information governance requirements.

Maintain confidentiality and handle personal data in accordance with data protection legislation and local policy.

Professional responsibilities

Practise in accordance with the NMC Code and within the NMC standards of proficiency for nursing associates, which form the ceiling of the role.

Maintain NMC registration, complete revalidation, and undertake preceptorship where newly qualified.

Escalate clinical concerns to the GP, pharmacist or frailty clinician without delay.

Undertake mandatory and role-specific training and participate in clinical supervision and appraisal.

Scope of Practice

Work within clearly defined protocols, competencies and delegated tasks agreed with the supervising registered clinician.

Do not diagnose conditions or prescribe medication.

Identify and escalate clinical concerns appropriately.

Work at all times within the NMC standards of proficiency for nursing associates and the NMC Code.

Records data in patient records systems promptly and accurately and to agreed standards.

Ensures appropriate use of read codes.

Participates in the auditing of practice activity as required.

Responsible for health and safety of themselves and others and actively co-operates with Health and Safety Policies and procedures.

Processes and actions incoming patient and hospital correspondence.

Attends in-house meetings, significant event audit meetings and other meetings as deemed necessary.

Ensures that the practice complaints system is adhered to at all times.

Awareness and compliance with all relevant guidelines e.g. data protection, confidentiality and health and safety.

Maintain current CPR and anaphylaxis certification and child/adult safeguarding training in line with local policies.

Measures of Success

The following measures support appraisal and service monitoring. Individual objectives will be agreed through appraisal.

Completion of assigned health checks.

Compliance with EMIS documentation templates.

Frailty scoring completion.

Carer wellbeing assessments documented.

Timely escalation of clinical risks.

Training & Development

Fully participates in training and development

Engages in a programme of ongoing support and feedback to maximise the benefit of the training and development plan.

Travel

Ability and willingness to travel across multiple sites is essential for this role

Confidentiality

In the course of seeking treatment, patients entrust us with, or allow us to gather, sensitive information in relation to their health. They do so in confidence and have the right to expect that staff will respect their privacy and act appropriately.

Information relating to patients, carers, colleagues, other healthcare workers or the business of the Practice may only be divulged to authorised persons in accordance with the Alliance policies and procedures relating to confidentiality, and the protection of personal and sensitive data.

Health & Safety

The post-holder will assist in promoting and maintaining their own and others health, safety and security as defined in the Practice Health & Safety Policy to include:

Identifying the risk involved in work activities and undertaking such activities in a way that manages those risks.

Using appropriate infection control procedures particularly those relating to needlestick injuries, maintaining work areas in a tidy and safe way and free from hazards.

Ensuring that all accidents or dangerous accidents are reported and investigated, and follow up action taken where necessary.

Maintain training in line with local policies.

Equality and Diversity

The post-holder will support the quality, diversity and rights of patients, carers and colleagues to include:

Acting in a way that recognizes the importance of peoples rights, interpreting them in a way that is consistent with current legislation.

Respecting the privacy, dignity, needs and beliefs of patients, carers and colleagues.

Behaving in a manner which is welcoming to and of the individual, is non-judgemental and respects their circumstances, feelings, priorities and rights.

Quality

The post-holder will strive to maintain quality within the Practice, and will:

Assess own performance and take accountability for own actions, either directly or under supervision.

Contribute to the effectiveness of the team by reflecting on own and team activities and making suggestions on ways to improve and enhanced the teams performance.

Work effectively with individuals in other agencies to meet patients needs.

Effectively manage own time, workload and resources.

Communication

The post-holder should recognise the importance of effective communication within the team and will strive to:

Communicate effectively with other team members.

Communicate effectively with patients and carers.

Recognise peoples needs for alternative methods of communication and respond accordingly.

The employer is Sunderland GP Alliance and the post-holder is expected to comply with the Alliances employment policies and procedures.

Person Specification

Other

Essential

• Appointment to this role will be subject to a satisfactory Standard/Enhanced DBS check
• The postholder must be able to travel reliably and independently between multiple sites

Motivation and Skills

Essential

• Compassionate, person-centred and resilient
• Effective team worker within an MDT

Qualifications

Essential

• Nursing Associate Foundation Degree or equivalent
• Current NMC registration as a Nursing Associate
• Completion of, or willingness to complete, training in dementia care and frailty assessment.
• Safeguarding adults training to the level required for the role.

Desirable

• Recognised training in dementia care
• Recognised training in frailty assessment

Experience

Essential

• Experience of delivering clinical observations and health checks
• Experience of working with older or vulnerable adults
• Understanding of dementia and frailty and their impact on patients and carers.
• Competence in clinical observations and health checks.
• Communication skills for working with vulnerable adults and carers.
• Ability to recognise deterioration and escalate concerns.
• Working knowledge of safeguarding adults and the Mental Capacity Act 2005.
• IT skills, including EMIS or similar clinical systems.

Desirable

• Experience in primary care, community or frailty settings
• Experience of caseload or follow-up working

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.

UK Registration

Applicants must have current UK professional registration. For further information please see NHS Careers website (opens in a new window).

Employer details

Employer name

Sunderland GP Alliance

Address

North East BIC

Wearfield

Sunderland

Tyne and Wear

SR5 2TA

United Kingdom

Employer's website

https://www.sunderlandgpalliance.co.uk/ (Opens in a new tab)

Job description

Job responsibilities

MAIN DUTIES AND RESPONSIBILITIES

• Working under the guidance of the referring GP, take referrals from a wide range of agencies, including PCNs, GP practices and multi-disciplinary teams as well as the wider system and occasionally via self-referral.
• Provide personalised support to individuals, their families and carers to empower people to take control of their lives, support low level mental health and promote self-care. Encourage people to live independently and improve their health access and outcomes, as a key member of the PCN multi-disciplinary team.
• Engage and develop trusting relationships by giving people time and focus on what matters to me and taking a holistic approach, based on the persons priorities and the wider determinants of health.
• Co-produce a simple personalised care and support plan to improve health and wellbeing, including introducing or reconnecting people to appropriate community groups and statutory services.
• Manage and prioritise own caseload in accordance with the needs and priorities of individuals on the caseload.
• Maintain a strong awareness and understanding of when it is appropriate or necessary to refer people back to other health professionals/agencies.
• Work with a diverse range of people and their communities, to draw on and increase the strengths and capacity of local community groups, enabling local VCSE organisations to receive social prescribing referrals.
• Work collaboratively with all local partners to contribute towards supporting the local VCSE organisations and community groups to become sustainable.
• Ensure that community assets are nurtured, through sharing intelligence regarding any gaps or problems identified in local provision with commissioners and local authorities.
• Educate non-clinical and clinical staff within their PCN multi-disciplinary teams on what services are available within the community and how to access them.

Role Specific Key Tasks

Education

• Promote all aspects of social prescribing across the PCN, Health & Social Care professionals and the wider system, including its role in self-management, addressing health inequalities and the wider determinants of health.
• Work in partnership with all local agencies to raise awareness of social prescribing and how partnership working can reduce pressure on statutory services, improve health access and outcomes and enable a holistic approach to care.
• Provide referral agencies with regular updates about social prescribing, including training for their staff and how to access information to encourage appropriate referrals.
• Promote low level mental health guidance, signpost to self-help and the most appropriate service.

Referrals

• Receive and action referrals for social prescriptions via agreed systems.
• Manage and prioritise referrals appropriately.
• Redirect referrals, using the agreed protocols, to more appropriate Social Prescribing Link Workers or agencies.
• Be proactive in developing strong links with all local agencies to encourage referrals.
• Support referral agencies to provide appropriate information about the person they are referring.
• Provide appropriate feedback to referral agencies about the people they referred.
• Work closely within the MDT and with GP practices within the PCN to ensure that the social prescribing referral codes are inputted into clinical systems.
• Adhere to data protection legislation and data sharing agreements.

Personalised Support

• Listen to and talk with people and their families about what matters to me by giving people time to tell their stories.
• Be proactive in encouraging equality and inclusion, through connecting with diverse local communities, particularly those communities that statutory agencies may find hard to reach.
• Meet people on a one-to-one basis, making home visits where appropriate within SGPA policies and procedures.
• Build trust and respect with the person, providing non-judgemental and non-discriminatory support, respecting diversity and lifestyle choices. Work from a strength-based approach focusing on a persons assets.
• Be a friendly and engaging source of information about health, wellbeing and prevention approaches.
• Help people identify the wider issues that impact on their health and wellbeing, such as debt, poor housing, being unemployed, loneliness and caring responsibilities.
• Help people maintain or regain independence through living skills, adaptations, enablement approaches and simple safeguards.
• Work with individuals to co-produce a simple personalised support plan to address the persons health and wellbeing needs, based on the persons priorities, interests, values, cultural and religious/faith needs and motivations.
• Identify what individuals expect from the groups, activities and services they are being connected to and what the person can do for themselves to improve their health and wellbeing.
• Where appropriate, physically introduce people to culturally appropriate community groups, activities and statutory services, ensuring they are comfortable, feel valued and respected. Follow up to ensure they are happy, able to engage, included and receiving good support.
• Where people may be eligible for a personal health budget, help them to explore this option as a way of providing funded, personalised support to be independent, including helping people to gain skills for meaningful employment, where appropriate.

Community Asset Development

• Provide a regular confidence survey to community groups receiving referrals, to ensure that they are strong, sustained and have the support they need to be part of social prescribing.
• Support community groups and VCSE organisations to receive referrals.
• Forge strong links with a wide range of local VCSE organisations, community and neighbourhood level groups, utilising their networks and building on whats already available to create a menu of diverse community groups and assets, who promote diversity and inclusion.
• Develop supportive relationships with local VCSE organisations, culturally appropriate community groups and statutory services, to make timely, appropriate and supported referrals for the person being introduced.
• Work collectively with all local partners to ensure community groups are strong and sustainable.
• Work with commissioners and local partners to identify unmet diverse needs within the community and gaps in community provision.
• Encourage people who have been connected to community support through social prescribing to volunteer and give their time freely to others, building their skills and confidence and strengthening community resilience.
• Develop a team of volunteers within your service to provide buddying support for people, starting new groups and finding creative community solutions to local issues.
• Encourage people, their families and carers to provide peer support and to do things together, such as setting up new community groups or volunteering.

Collaborative working

• As part of the PCN multi-disciplinary team, build close working relationships with staff in GP practices within the local PCN, attending relevant MDT meetings, giving information and feedback on social prescribing.
• Seek advice and support from the GP teams and/or identified individual(s) to discuss related concerns (e.g. abuse, domestic violence and support with mental health), referring the patient back to the GP or other suitable health professional if required.
• Work with established VCSE organisations and existing Social Prescribing Link Workers to provide a robust and consistent approach to our Sunderland people.
• Explore ways of working and share good practice and learning across all social prescribing roles within the system.

Data Collection

• Encourage people, their families and carers to provide feedback and to share their stories about the impact of social prescribing on their lives.

Professional Development

• Work with the GP teams and/or line manager to undertake continual personal and professional development, taking an active part in reviewing and developing the roles and responsibilities.
• Adhere to organisational policies and procedures, including confidentiality, safeguarding, lone working, information governance, equality, diversity and inclusion training and health and safety.
• Work with the GP teams to access regular clinical supervision, where appropriate, to enable you to deal effectively with the difficult issues that people present.

Service Development

• Seek regular feedback about the quality of the service and impact of social prescribing on referral agencies.
• Work as part of the healthcare team to seek feedback, continually improve the service and contribute to business planning.
• Contribute to the development of policies and plans relating to equality, diversity and health inequalities.

Leadership

• Be a system leader in the development, delivery and education of social prescribing, ensuring involvement where value can be added.
• Provide role coaching and mentoring for all staff where appropriate.

Other

• Undertake any tasks consistent with the level of the post and the scope of the role, ensuring that work is delivered in a timely and effective manner.
• Duties may vary from time to time, without changing the general character of the post or the level of responsibility.

Person Specification

Motivation and Skills

Essential

• Ability to identify risk to self and others, Identifying and reporting safeguarding incidents
• Outstanding organisational skills
• Work effectively and collaboratively as part of a team but also autonomously.
• High level and adaptable communication skills across a range of individuals of all ages, backgrounds and cultures with varying social and emotional needs
• Able to respond to challenges with resilience and manage situations calmly and professionally.
• Promote and maintain good working relationships with a variety of external partners.
• Experience of accurately collecting, recording information and data whilst maintaining confidentiality
• Work on own initiative but within constraints of the role
• Provide motivational coaching with the ability to inspire trust and confidence
• Able to work under pressure and emotionally resilient

Desirable

• Understanding the impact of economic and environmental factors on people's health and wellbeing
• Mental Health First Aid

Qualifications

Essential

• Demonstrable commitment to personal and professional development
• Proficient in the use of Microsoft Office applications.
• Qualification or training in motivational coaching, or equivalent experience

Desirable

• PCI Accredited
• qualification in Social Prescribing

Experience

Essential

• Ability to competently use technology and IT systems including word processing, email and the internet to create simple personalised plans with individuals
• Experience of supporting people, their families and carers in a paid or unpaid capacity
• Experience of working in a community setting
• Experience of handling confidential information.
• Experience of collecting and recording information and data
• Experience of supporting people, their families and carers in a paid or unpaid capacity
• Experience of supporting people, their families and carers with low level mental health issues
• Experience of working in a community setting
• Ability to identify risk to self and others, Identifying and reporting safeguarding incidents

Desirable

• Experience of working in or with voluntary organisations or groups in a paid or unpaid capacity
• Experience of working collaboratively with different organisations, building trust, confidence and partnerships
• Extensive knowledge of local services within a Sunderland locality through either living or working within one of the wider Sunderland settings.
• Experience of working with GPs and/or other Health or Social Care providers or knowledge of how systems work Experience of working collaboratively with different organisations, building trust, confidence and partnerships

Other

Essential

• Understands the principles of equality and diversity.
• A firm commitment to CPD
• Full UK driving licence with use of own car
• Ability to travel across Sunderland if required
• Meet DBS standards and Criminal Record checks

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.

Employer details

Employer name

Sunderland GP Alliance

Address

North East BIC

Wearfield

Sunderland

Tyne and Wear

SR5 2TA

United Kingdom

Employer's website

https://www.sunderlandgpalliance.co.uk/ (Opens in a new tab)

Job description

Job responsibilities

• Answer the telephone as a priority
• Book/cancel appointments
• Take messages accurately and pass on in a timely manner
• Organise home visit requests
• Deal with general enquiries and complaints
• To forward any queries relating to prescriptions to the Pharmacy Technicians
• Give out pathology results
• Register new patients and temporary residents and make up paper records
• Process deducted patients and send records to Primary Care Services Agency
• Greet and direct patients and visitors
• Organise translators
• Respond to the needs of GPs and Nurses to enable efficient clinics
• Input and extract information from the Practice computer system
• Update the clinical system with information eg smoking, ethnicity
• Action change of address notification
• Any other filing, record keeping and distribution of documents as appropriate
• Effectively liaise with Practice, Primary Care Organisations, patients and other external organisations to assist promptly with the resolution and administration of queries
• Fully utilise EMISWeb and other IT systems
• Monitor and check tasks and work flows
• Communicate effectively with the reception team to ensure policies and procedures are kept up to date
• Keep directories and data bases up to date to ensure an efficient work flow
• Demonstrate duties to new or less experienced staff
• Resolve job related issues, including patient documentation and help resolve minor problems
• Photocopying
• Dealing with mail internal and external
• Attend meetings when required
• To work safely at all times in accordance with legislation and Practice policies and procedures
• Be flexible both in the availability and being able to cover for colleagues absent from work due to annual leave or sickness
• Any other reasonable duties requested by the Practice Manager or GP
• This list is not exhaustive

In addition to the above, the post holder will show respect and courtesy to patients and colleagues, maintain confidentiality of patient and other Practice information at all times. Working occasional extra hours may be required.

The job description is not exhaustive and may be adjusted periodically after review and consultation. You will be expected to carry out reasonable duties which may be requested from time to time.

Working Relationships

• General Practitioners
• Practice Manager and Team Leader
• Other members of secretarial team
• Members of the Practice/community nursing team
• Other members of the Primary Health Care Team
• Patients
• Outside agencies eg Secondary Care Trusts, Community Services, PCN

All members of staff may be asked to attend periodic Staff Meetings, which may be held outside their normal working hours. They may also be required to work extra hours covering for holidays and sickness. This may include Saturday mornings and possibly weekend work in future on a rota basis.

Review

• The post and the job description reflect the current requirements and objectives of the post. As the duties of the post develop and change, the post holder may be required to carry out other responsibilities.
• Whilst there will be consultation on such issues, employees should understand that, if agreement cannot be reached, then the employer reserves the right to make changes to job descriptions where it considers such changes necessary.

Travel

Ability and willingness to travel across multiple sites is essential for this role

Confidentiality

• In the performance of the duties outlined in this job description, the post-holder may have access to confidential information relating to patients and their carers, Practice staff and other healthcare workers. All such information from any source is to be regarded as strictly confidential.
• Information relating to patients, carers, colleagues, other healthcare workers or the business of the Alliance may only be divulged to authorized persons in accordance with the Alliances policies and procedures relating to confidentiality, and the protection of personal and sensitive data.

Health & Safety

The post-holder will assist in promoting and maintaining their own and others health, safety and security as defined in the Alliances Health & Safety Policy to include:

• Identifying the risk involved in work activities and undertaking such activities in a way that manages those risks.
• Ensuring that all accidents or dangerous accidents are reported and investigated and follow up action taken where necessary.

Equality and Diversity

The post-holder will support the quality, diversity and rights of patients, carers and colleagues to include:

• Acting in a way that recognizes the importance of peoples rights, interpreting them in a way that is consistent with current legislation.
• Respecting the privacy, dignity, needs and beliefs of patients, carers and colleagues.
• Behaving in a manner which is welcoming to and of the individual, is non-judgemental and respects their circumstances, feelings, priorities and rights.

Quality

The post-holder will strive to maintain quality within the Alliance, and will:

• Alert other team members to issues of quality and risk.
• Assess own performance and take accountability for own actions, either directly or under supervision.
• Contribute to the effectiveness of the team by reflecting on own and team activities and making suggestions on ways to improve and enhanced the teams performance.
• Work effectively with individuals in other agencies to meet patients needs.
• Effectively manage own time, workload and resources.

Communication

The post-holder should recognize the importance of effective communication within the team and will strive to:

• Communicate effectively with other team members.
• Communicate effectively with patients and carers.
• Recognise peoples needs for alternative methods of communication and respond accordingly.

Person Specification

Experience

Essential

• Proven experience of working in an NHS setting.
• Working knowledge of medical reception duties.
• Experience of handling confidential information.
• Proven experience of working with patients/public.
• Ability to handle telephone queries and understand when to involve others.
• Record and process messages accurately.
• Knowledge of System One.
• Care Coordinator training is preferred or willing to complete

Desirable

• Trained and proficient in the use of Microsoft Word, Excel, PowerPoint, Outlook and other Microsoft Office applications.
• Trained in the requirements of GDPR.
• Care Coordinator training is preferred or willing to complete

Qualifications

Essential

• GCSE or equivalent in Mathematics and English.

Desirable

• Trained and proficient in the use of Microsoft Word, Excel, PowerPoint, Outlook and other Microsoft Office applications.
• Trained in the requirements of GDPR.
• Care Coordinator training is preferred or willing to complete

Motivation and Skills

Essential

• Good interpersonal skills with the ability to communicate effectively with a diverse range people.
• Ability to work effectively and collaboratively within a team and on own initiative.
• Can demonstrate excellent communication skills.
• Ability to be flexible and adapt to changing and challenging circumstances

Other

Essential

• Appointment to this role will be subject to a satisfactory Standard DBS check

Desirable

• The postholder must be able to travel reliably and independently between multiple sites

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.

Employer details

Employer name

Sunderland GP Alliance

Address

South Hylton Medical Centre

2 Union Street

Sunderland

Tyne And Wear

SR4 0LS

United Kingdom

Employer's website

https://www.sunderlandgpalliance.co.uk/ (Opens in a new tab)