About Us:
The Confederation, Hillingdon CIC works with General Practice and other healthcare providers to deliver its vision for Hillingdon to deliver the best primary care outcomes for patients in the whole of London. We are a not-for-profit community interest company. The Confederation works to develop and support individual GP practices, PCNs and Neighbourhoods and their changing needs. We deliver excellent clinical services ourselves both at scale and complementary to General Practice. We are the provider representative voice for local General Practice into the wider NHS and other Partners. We are of the NHS but independent, innovative and transformational.
The Confederation determines to develop as an attractive place to work, providing rewarding roles and opportunities to grow in order to attract and retain great staff that in turn delivers our vision.
Our Values:
Location
The role is based in Colne Union PCN in Yiewsley / West Drayton.
The PCN covers the following practices:
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High Street Practice
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Oakland Medical Centre
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Otterfield Medical Centre
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The Green Medical Centre
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Yiewsley Family Practice
Job Summary:
The post holder will be an experienced registered nurse working at enhanced practice level across the Primary Care Network, with a specialist focus on mental health and learning disabilities. Working autonomously within an agreed scope of practice, the post holder will provide high-quality, person-centred care for adults with severe mental illness, common mental health problems, learning disabilities, autism, neurodevelopmental needs and associated physical health inequalities. They will use specialist knowledge, enhanced assessment skills and evidence-based clinical decision-making to assess need, formulate and review personalised care plans, monitor treatment, support recovery and independence, and make timely referrals or escalation where required.
The post holder will work closely with general practice, community mental health and learning-disability services, social care, pharmacy and voluntary-sector partners. They will contribute to annual physical health checks, proactive review, medicines monitoring, prevention, early identification of deterioration, crisis planning, safeguarding and reduction of health inequalities. They will provide clinical leadership, support the development of colleagues and lead or contribute to quality improvement, audit and service development. The post holder will recognise the limits of their competence and seek appropriate advice or refer to an advanced practitioner, GP, psychiatrist, community mental health team, learning-disability service or other clinician when needed.
Primary Responsibilities
Clinical Practice
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Work autonomously and accountably within the NMC Code, local policies, agreed clinical pathways and the limits of the role and individual competence.
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Undertake comprehensive, holistic assessments of mental health, learning-disability needs, physical health, cognition, communication, social circumstances, functioning, strengths, risks and protective factors.
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Use enhanced mental health and physical assessment skills to identify deterioration, relapse, unmet need, adverse treatment effects, diagnostic overshadowing and conditions requiring urgent medical or specialist review.
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Develop, implement and evaluate personalised care and support plans in partnership with patients, families, carers, advocates and the multidisciplinary team, promoting recovery, independence and quality of life.
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Provide enhanced-level management for one or more defined specialist areas, such as severe mental illness, depression and anxiety, learning disabilities, autism, dementia, neurodevelopmental needs or another locally agreed priority.
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Complete and coordinate physical health reviews for people with severe mental illness, including relevant observations, lifestyle review, cardiovascular and metabolic risk assessment, blood tests, screening, medicines monitoring and follow-up within competence.
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Undertake or coordinate annual health checks and health action plans for people with learning disabilities, ensuring reasonable adjustments, accessible communication and timely action on identified physical and mental health needs.
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Review treatment effectiveness and, where qualified as an independent prescriber, prescribe, deprescribe and review medicines in accordance with evidence, national guidance, local formularies and professional accountability.
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Monitor the safety and effectiveness of psychotropic and other medicines, support adherence, identify adverse effects and interactions, and arrange appropriate investigation, referral or specialist review.
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Use psychologically informed and evidence-based approaches to support self-management, emotional wellbeing, relapse prevention, behaviour change, coping strategies and recovery goals within scope of practice.
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Assess risk relating to self-harm, suicide, self-neglect, exploitation, abuse, violence, vulnerability, deterioration or carer breakdown, and develop proportionate safety, crisis and escalation plans.
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Recognise mental health crisis, acute behavioural change, delirium, severe distress, safeguarding concerns and urgent or emergency presentations; initiate immediate care and escalate or refer without delay.
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Assess decision-making capacity relevant to the care or treatment being considered, support communication and involvement, and follow legal and organisational requirements for consent and best-interest decision-making.
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Undertake home, care home, supported-living or community visits when required by the service and when clinically appropriate.
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Maintain accurate, contemporaneous and complete clinical records, including clear documentation of assessment, formulation, clinical reasoning, risk, capacity, consent, plans, advice, escalation and outcomes.
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Population Health and PCN Service Delivery:
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Use practice and PCN data to identify people with severe mental illness, learning disabilities, autism or other mental health needs who are at risk, overdue review, experiencing poor access or likely to benefit from proactive intervention.
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Support achievement of relevant Quality and Outcomes Framework, PCN, local enhanced service and contractual priorities while maintaining person-centred and clinically appropriate care.
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Improve uptake and quality of severe mental illness physical health checks, learning-disability annual health checks, screening, immunisation and other prevention activity through proactive recall, follow-up and reasonable adjustments.
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Identify and address physical health inequalities, premature mortality risks, barriers to access and unmet health needs affecting people with mental illness or learning disabilities.
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Support proactive care for people with complex mental, physical and social needs through risk stratification, anticipatory care, personalised care planning and multidisciplinary review.
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Contribute to enhanced access and other PCN-wide clinical services, including delivery across different member practices and community settings where required.
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Work with integrated neighbourhood teams and partner organisations to improve continuity, care coordination, crisis prevention and outcomes for people who may otherwise experience fragmented care.
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Evaluate the impact of clinical interventions and service changes using agreed outcome measures, patient and carer feedback, inequalities data and audit findings.
Communication
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Use sensitive, inclusive and effective communication to support informed choice, consent and shared decision-making.
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Adapt communication to meet language, sensory, cognitive, cultural and health-literacy needs, using interpreting or accessible information services where appropriate.
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Communicate complex or sensitive information to patients and carers with compassion, including discussions about deterioration, risk, treatment burden and changes to care.
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Provide clear advice on self-care, symptom monitoring, when to seek help and how to access appropriate services.
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Act as an advocate for patients and carers, supporting their involvement in care and respecting their right to accept or refuse treatment.
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Maintain effective communication with colleagues across the PCN, practices, community services, hospitals, mental health services, social care and the voluntary sector.
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Address concerns and conflict professionally, escalating unresolved risks through the appropriate governance route.
Delivering a Quality Service
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Recognise and work within own competence and professional code of conduct as regulated by the NMC
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Produce accurate, contemporaneous and complete records of patient consultation, consistent with legislation, policies and procedures
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Prioritise, organise and manage own workload in a manner that maintains and promotes quality
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Deliver care according to NSF, NICE guidelines and evidence-based care
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Assess effectiveness of care delivery through self and peer review, benchmarking and formal evaluation
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Initiate and participate in the maintenance of quality governance systems and processes across the organisation and its activities
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Utilise the audit cycle as a means of evaluating the quality of the work of self and the team, implementing improvements where required
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In partnership with other clinical teams, collaborate on improving the quality of health care responding to local and national policies and initiatives as appropriate
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Evaluate patients response to health care provision and the effectiveness of care
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Support and participate in shared learning across the practice and wider organisation
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Use a structured framework (e.g. root-cause analysis) to manage, review and identify learning from patient complaints, clinical incidents and near-miss events
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Assess the impact of policy implementation on care delivery
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Working with the practice management monitor and develop the performance of the GPN team in accordance with local policies
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Contribute to the appraisal of the performance of the team, providing feedback as appropriate
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Understand and apply legal issues that support the identification of vulnerable and abused children and adults, and be aware of statutory child/vulnerable patients health procedures and local guidance
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Working with practice management to ensure the whole team have skills and knowledge regarding domestic violence, vulnerable adults, substance abuse and addictive behaviour. Provide guidance and support to ensure appropriate referral if required
Leadership Personal and People Development
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Act as a clinical leader in the delivery of practice nursing services ensuring that the needs of the patient are a priority
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Take responsibility for own learning and performance including participating in clinical supervision and acting as a positive role model
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Support staff development in order to maximise potential
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Actively promote the workplace as a learning environment, encouraging everyone to learn from each other and from external good practice
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Encourage others to make realistic self-assessment of their application of knowledge and skills, challenging any complacency or actions that are not in the interest of the public and/or users of services
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Critically evaluate and review innovations and developments that are relevant to the area of work
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Enlist support and influence stakeholders and decision-makers in order to bring about new developments in the provision of services
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Work with practice management to ensure sufficient staff of appropriate ability, quality and skill-mix are available to meet current and future service delivery, that selection and recruitment processes are effective and that equality of treatment of the team incorporates quality HR principles and processes
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Contribute to the development of local guidelines, protocols and standards
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Maintain effective communication with those responsible for the overall commissioning and procurement process
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Maintain active involvement in the planning and processes of practice-based commissioning or similar initiatives
Team Working
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Understand own role and scope and identify how this may develop over time
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Work as an effective and responsible team member, supporting others and exploring the mechanisms to develop new ways of working
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Delegate clearly and appropriately, adopting the principles of safe practice and assessment of competence
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Create clear referral mechanisms to meet patient need
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Prioritise own workload and ensure effective time-management strategies are embedded within the culture of the team
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Work effectively with others to clearly define values, direction and policies impacting upon care delivery
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Discuss, highlight and work with the team to create opportunities to improve patient care
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Manage and lead on the delivery of specifically identified services or projects as agreed with the practice management team
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Agree plans and outcomes by which to measure success
Management of Risk
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Manage and assess risk within the areas of responsibility, ensuring adequate measures are in place to protect staff and patients
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Monitor work areas and practices to ensure they are safe and free from hazards and conform to health, safety and security legislation, policies, procedures and guidelines
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Ensure appropriate supervision of safe storage, rotation and disposal of vaccines and drugs. Oversee the monitoring, stock control and documentation of controlled drug usage according to legal requirements where appropriate
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Working with the practice management, ensure the nursing team has access to and undertakes mandatory and statutory training requirements
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Apply infection-control measures within the practice according to local and national guidelines
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Advocate for policies that reduce environmental health risks, are culturally sensitive and increase access to health care for all
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Interpret national strategies and policies into local implementation strategies that are aligned to the values and culture of general practice
Managing Information
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Use technology and appropriate software as an aid to management in planning, implementation and monitoring of care, presenting and communicating information
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Review and process data using accurate Read codes in order to ensure easy and accurate information retrieval for monitoring and audit processes
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Manage information searches using the internet and local library databases
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Understand responsibility of self and others to the practice and primary care trust regarding the Freedom of Information Act
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Collate, analyse and present clinical data and information to the team
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Communicate essential financial restraints with the team and discuss with them ideas for effective and efficient working within these constraints
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Manage, if agreed, the nursing budget within financial principles
Learning and Development
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Undertake mentorship for more junior staff, assessing competence against set standards
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Disseminate learning and information gained to other team members in order to share good practice and inform others about current and future developments (e.g. courses and conferences)
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Assess own learning needs and undertake learning as appropriate
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Provide an educational role to patients, carers, families and colleagues in an environment that facilitates learning
Person Specification
Essential Criteria
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Current registration with the Nursing and Midwifery Council as a Registered Mental Health Nurse or Registered Learning Disabilities Nurse, with no restriction affecting the role
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Nursing degree or equivalent professional qualification
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Relevant postgraduate modules or recognised CPD supporting enhanced-level practice in mental health, learning disabilities, autism or neurodevelopmental care
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Independent/Supplementary Nurse Prescribing qualification (V300), or currently undertaking with completion agreed
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Recognised qualification or competency in at least one relevant specialist area, such as severe mental illness, learning disabilities, autism, dementia, psychosocial interventions or behavioural support
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Current basic life support training and evidence of competence in physical health assessment
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Training in suicide and self-harm risk assessment, crisis response or equivalent
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Mentorship, practice assessor or teaching qualification/experience
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Significant post-registration nursing experience
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Recent experience in mental health, learning-disability, primary care or a closely related community setting
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Autonomous management of patients with mental health or learning-disability needs within an agreed scope of practice
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Experience caring for people with severe mental illness, learning disabilities, autism, multimorbidity or complex psychological, physical and social needs
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Enhanced mental health assessment, formulation, clinical reasoning and decision-making skills within scope of practice
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Physical health assessment and monitoring for people with severe mental illness or learning disabilities
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Safe medicines management and prescribing practice, including psychotropic monitoring, adherence, adverse effects and interactions
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Assessment and management of risk relating to self-harm, suicide, self-neglect, vulnerability, exploitation, violence or deterioration
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Experience of crisis planning, relapse prevention, safety planning and timely escalation to specialist or urgent services
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Learning-disability annual health checks, health action plans or equivalent proactive health review
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Severe mental illness physical health checks and associated follow-up
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Personalised care planning, recovery-focused practice, shared decision-making and care coordination
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Knowledge and application of safeguarding responsibilities for children and adults at risk
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Knowledge of consent, capacity, best-interest decision-making, advocacy and appropriate information sharing
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Understanding of diagnostic overshadowing, reasonable adjustments, accessible information and the physical health inequalities affecting people with mental illness or learning disabilities
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Knowledge of NICE guidance, professional standards, QOF and relevant PCN/local service requirements
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Understanding of population health management, prevention, inclusion health and health inequalities
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Accurate clinical coding, data quality and use of clinical systems such as EMIS or SystmOne
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Clinical audit, quality improvement and evaluation of outcomes
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Incident reporting, complaint management and learning from patient-safety events
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Development or review of clinical protocols, referral pathways, guidelines or standard operating procedures
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Supervision, mentorship and competency development of nursing or support staff
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Clinical leadership and contribution to service development or redesign
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Effective multidisciplinary and cross-organisational working with mental health, learning-disability, social care and primary care services
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Confident use of digital technology, remote consultation tools and evidence resources
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Knowledge of infection prevention, cold-chain management and safe handling of medicines and vaccines
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Self-directed, reflective and accountable practitioner
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Highly motivated, compassionate and committed to high-quality person-centred care
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Flexible team player able to work across professional and organisational boundaries and travel between PCN sites
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Satisfactory occupational health clearance and enhanced DBS check appropriate to the role
Desirable Criteria
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Clinical supervision or safeguarding supervision training
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Leadership or management qualification
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Additional qualification in learning disabilities, autism, cognitive assessment, dementia, psychological therapies or positive behavioural support
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Experience supporting autistic people or people with neurodevelopmental or communication needs
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Research awareness and critical appraisal of evidence
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Project or change-management experience
