Long-Term Visiting Practice Nurse

Long-Term Conditions Visiting Practice Nurse

To provide high-quality, patient-centred long‑term condition service to housebound patients and patients residing in residential and nursing homes across Torquay Primary Care Network.

The role focuses on the proactive management of long‑term conditions through annual reviews, care planning, health promotion and preventative care, contributing to improved patient outcomes, reduced health inequalities and compliance with QOF and enhanced service requirements within the NHS
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KEY RESPONSIBILITIES

In addition to the full scope of Practice Nurse duties, the post holder will:

• Undertake home-based and care‑home-based QOF reviews for patients with long‑term conditions including Diabetes, Asthma, COPD, Hypertension, Coronary Heart Disease (CHD), Dementia, and mental health conditions.
• Complete learning disability annual health checks in patients’ places of residence.
• Undertake mental health annual reviews in line with national and local guidance.
• Provide home‑based vaccinations
  , including seasonal influenza and other vaccinations in line with PGDs.
• Develop, update and review personalised care plans following clinical assessments.
• Identify deterioration or unmet needs and raise the appropriate issues with GPs or community services.
• Promote self‑management, lifestyle modification and health education for patients and carers.

Torquay PCN – Brunel Medical Practice, Southover Medical Practice, Chelston Hall Surgery and Croft Hall Medical Practice.

In addition to the full scope of Practice Nurse duties, the post holder will:

• Undertake home‑based and care‑home‑based QOF reviews for patients with long‑term conditions, including Diabetes, Asthma, COPD, Coronary Heart Disease (CHD), Dementia and mental health conditions.
• Complete learning disability annual health checks in patients’ places of residence.
• Undertake mental health annual reviews in line with national and local guidance.
• Provide home‑based vaccinations
  , such as seasonal influenza and other vaccinations, in line with PGDs.
• Develop, update and review personalised care plans following clinical assessments.
• Identify deterioration or unmet needs and raise the appropriate issues with GPs or community services.
• Promote self‑management, lifestyle modification and health education for patients and carers.

• The post holder will maintain full competence in Practice Nurse duties, including:
  • Assessment, planning, implementation and evaluation of patient care.
  • Recording and monitoring: height, weight, BMI; blood pressure, pulse, respiration, temperature; pulse oximetry; urinalysis; ECG recording; phlebotomy and specimen handling; wound care and dressings; general injections and immunisations (including flu and pneumococcal); health promotion and lifestyle advice; telephone advice and triage; accurate and timely electronic documentation using clinical systems with appropriate coding, recalls and GMS/QOF data entry.

• interim and annual reviews in line with practice protocols.
• Asthma and COPD annual reviews in line with practice guidelines.
• Mental health annual review checks.
• Depo‑Provera administration.
• Doppler assessments (under supervision of the Lead Nurse).
• Strict adherence to infection prevention and control policies.

• Administer medicines and vaccinations safely in accordance with PGDs, PSDs and cold‑chain requirements.
• Identify issues relating to concordance, side effects and polypharmacy and raise them as required.
• Collaborate with GPs, pharmacists and the wider MDT to optimise medicines management.

• Recognise, respond to and raise safeguarding concerns relating to adults at risk and children.
• Work in accordance with safeguarding legislation, local safeguarding policies and practice procedures.
• Maintain mandatory safeguarding training appropriate to the role.

• Adhere to lone‑working policies and personal safety procedures at all times.
• Undertake dynamic risk assessments before and during home visits.
• Use…