JOB DESCRIPTION
JOB DETAILS:
Job Title Cluster Chronic Conditions Nurse
Pay Band 6
Hours of Work and Nature of Contract :Fixed term 2-year contract – 37.5 from September 2026
Division/Directorate City Cluster
Department Primary Care
Base Kingsway Surgery
ORGANISATIONAL ARRANGEMENTS:
Managerially Accountable to: Senior Nurse for Primary Care/GP Cluster Lead
Reports to: Name Line Manager Cluster GP Lead / Clinical Supervisor/BDIM or Equivalent
Professionally Responsible to: GP Cluster Lead
Our Values
In this Health Board we aspire to be driven by our values; where every person that works for us, regardless of their role, is expected to demonstrate the values of “caring for each other”, “working together” and “always improving”.
Add organisational statement on values and behaviours
Job Summary/Job Purpose:
The City Health Cluster Network has agreed to deploy funding to address potential health inequalities amongst housebound patients and those with limited mobility/support living in the Network area through improving access to nurse-led chronic disease monitoring in the patients home. The Chronic Conditions Nurse role will be attached to City Health Cluster Network to lead this Chronic Conditions housebound service for Cluster wide patients.
The Registered Nurse appointed will be responsible for providing a domiciliary and practiced based care in the City Health area for the coordination, management and monitoring of the care of housebound patients with long-term chronic illness (for example heart disease, COPD and diabetes).
Through a structured programme of monitoring the primary focus of this role will be on service quality, through specialist assessments and reviews of health care needs, the optimisation of care where co-morbidity exists, maximising wellbeing, self-empowerment, and quality of life.
The Chronic Conditions nurse will be an expert generalist whose role will involve providing advanced chronic disease management care in the community setting. The post holder will work autonomously in patients’ homes and in primary care premises, to co-ordinate the care needs of those patients on the caseload.
The Chronic Conditions Nurse will work in collaboration with partner organisations and other professionals to ensure patients’ health care needs are met appropriately and hospital admissions are reduced.
DUTIES/RESPONSIBILITIES:
The Chronic Conditions Nurse will:
Assess patients, plan and implement care, provide specialist advice to both patients and healthcare colleagues and act as a resource for other community nurses.
Maintain comprehensive and contemporaneous records for each patient in line with SBUHB, NMC and local policy, liaising closely with the patient’s GP and the Practices’ own specialist nurses where needed.
Undertake relevant Risk Assessments associated with this role and working environments as indicated in the SBUHB Health and Safety Policies and Risk Management Strategy, and act on any findings in a timely manner.
Be responsible for the supervision and teaching of staff and students as required.
Promote clinical governance within all settings, encouraging the development and participating in clinical audit, research evidenced based practice and reflective practice and life-long learning.
Adopt a flexible approach to the duties of the post; taking into account the changing needs and development of the Community Networks, Community Resource Team and changes in Locality Community Health & Social Care service provision
Undertake an initial patient assessment including the taking of a comprehensive history, perform a comprehensive and systematic physical examination and establish baseline data to inform the development of a specialised, individual and comprehensive care plan.
Make clinical decisions and explore new ways of working within the role.
Consider signs and symptoms, direct patient tests, laboratory tests results, and other measures to function when reviewing the condition of the patient.
Use expert knowledge and clinical judgement to identify the diagnosis of complex facts and situations, ensuring practice is underpinned by appropriate training.
Collaborate across the wider team to plan and implement treatment for acute illness/injury/chronic illness as required.
Monitor indicators of chronic disease, anticipating possible decline and proactively managing this to enhance well-being, and to maintain independence.
Plan interventions in the light of patients expressed outcomes, facilitating discussion with the family and significant others concerning end of life issues where appropriate.
Undertake minor illness clinics within cluster practices within own scope of practice.
Undertake Health Promotion activities including flu vaccination.
Review care and treatment plans regularly, communicating the outcomes of reviews to the patients’ GP in a timely and comprehensive manner
Take an active role in auditing and monitoring all components of care delivery.
Continually review and develop competencies underpinned by research and evidence based practise.
Be accountable for own professional actions; not directly supervised.
Function as an expert nurse for patients with complex chronic conditions.
Provide occasional physical support of patients including potential contact with and assessment of body fluids
Plan own activities and adjust plans to accommodate any unpredictable events, eg. Assessing an individual who has become acutely unwell or developed an exacerbation of a chronic condition, or to deal with urgent service issues.
Care Co-ordination
Integrate care across all care settings, preventing duplication, fragmentation and delay occurring as patients move between care settings.
Build relationships across professional and organisational boundaries, breaking down barriers and smoothing the patient journey.
Work with other Health Care Professionals to monitor, manage and treat Chronic Conditions, including non-drug based treatment methods, utilising robust management plans in line with national and local policies and patient needs.
Assess, plan, implement and evaluate individual treatment plans for patients with Chronic Conditions and working collaboratively with practices within the designated cluster to maintain quality patient care for housebound patients.
Review medication for therapeutic effectiveness within your scope of practice and in collaboration with a GP or non-medical prescriber. Ensure national and local policies are adhered to when devising or amending treatment plans.
Assist in planning, co-ordinating and supervising the workload of junior nursing staff and HCSWs associated with the Chronic Conditions Management service.
Participate as a key member of the multidisciplinary team through development of collaborative and innovative practice.
Communication
Be able to communicate effectively will all patients, colleagues and associated stakeholders, and support and encourage patient/carer interventions and education.
Enable and support integration of patient’s wishes into care planning for both current and future care needs.
Disseminate information throughout the multidisciplinary team, taking into account the need for confidentiality.
Be able to discuss highly sensitive and complex information with patients, relatives/carers and colleagues offering empathy and reassurance.
Respect cultural and language difficulties and address communication barriers in a positive non-discriminatory
manner
Communicate in a manner which is easily understood by patients and their relatives.
Safely and effectively use all relevant forms of communication such as oral, written and electronic formats
Ensure practice IT systems are kept updated with accurate patient information.
Education and Training
Be responsible for highlighting any identified personal educational and training needs to Cluster and Health Board Line Managers. Ensure all training and educational needs are discussed within your annual appraisal.
Empower patients and carers to evaluate possible treatment options as their disease progresses, and evaluate relative benefits and burdens of these options.
Be responsible for ensuring appropriate delegation of tasks to Health Care Support Workers and Registered Nurses in line with their scope of practice.
Participate in the development of the team’s knowledge about disease processes and treatments.
Play an active role in disseminating knowledge about chronic disease and its management within primary care, mentoring new Primary Care nurses as required and supporting education of other primary care colleagues.
Provide learning opportunities in the clinical setting that support the wider primary care team. Undertake formal teaching sessions for organisations, students and staff groups where possible.
Provide learning opportunities for wider Swansea health and social care community to improve the awareness of chronic conditions and the needs of people with chronic conditions.
Continue to develop own expert clinical competence in line with evidence based practice.
Leadership and Management
Ensure the SBUHB Values are adopted and adhered to at all times.
Take responsibility for the day-to-day operational management of the Chronic Conditions Management service for identified housebound patients within the designated Cluster.
Monitor, audit and evaluate clinical effectiveness in accordance with SBUHB policies and procedures.
To be a clinical resource for members of the healthcare team, providing advice and assisting with treatment and provision of care.
Comment on policies, procedures and guidelines pertinent to this role, ensuring they are implemented, monitored and updated as necessary.
Promote effective team working, disseminating knowledge and skills as necessary.
Support changes in service delivery in accordance with evidence-based standards and policies.
Act as an advocate at all times, both for patients and the service. Take a lead role in advocating for the patient in order to obtain optimal treatment and symptom control, thereby improving quality of life.
Support the clinical governance strategy as a means of improving the service to patients and staff.
Professional
Work within the NMC Code of Conduct at all times.
Remain updated and ensure that clinical practice is evidence based.
Maintain Professional Registration and Revalidation.
Maintain a personal development plan and professional portfolio.
Adhere to consent and confidentiality requirements.
Contribute to the appraisal process, providing feedback on performance.
Escalate any concerns/ issues to the GP Leads and Health Board Line Manager where needed.
Responsibilities for Information Resources
Scrutinise professional record keeping in line with NMC professional standards.
Input, review and process data using accurate READ codes to ensure easy and accurate retrieval for monitoring and audit processes.
Manage information searches using evidence based clinical resources to retrieve relevant information for patients and others on specific conditions.
Understand the responsibility of self and others regarding the Freedom of Information Act.
Equality and Diversity
Ensure the promotion of equality and diversity and a non-discriminatory culture.
Treat all service users, families, carers and colleagues with dignity & respect.
Act as a role model in the observance of equality and diversity good practice.
Accept the rights of individuals to choose/participate in their care or to refuse care.
PERSON SPECIFICATION
ATTRIBUTES
Qualifications and/or Knowledge
ESSENTIAL
Registered Nurse - currently registered with the NMC
Hold a first degree in Nursing studies
Evidence of Diploma or higher level training in Chronic Conditions Management (or equivalent)
Evidence of ongoing, relevant CPD
Understanding of clinical audit
Knowledge of Professional Nursing agenda, Clinical Governance and Quality and Safety
Knowledge of national policies, guidance and standards relevant to this role
DESIRABLE
Clinical assessment module
ECDL
Level 3 POVA
Mentorship qualification
METHOD OF ASSESSEMENT Application form and pre employment checks
Experience
ESSENTIAL
Clinically credible with experience of multi-disciplinary working
Extensive experience of working within Primary Care and/or Community services
Post registration Nursing experience
Knowledge and experience of managing patients with Chronic Conditions
DESIRABLE
Service improvement experience
Experience of nurse triage/workload prioritisation
Mentorship and teaching experience
METHOD OF ASSESSMENT: Application form and interview
Aptitude andAbilities
ESSENTIAL
Excellent communication skills, both verbal and written
Clinical skills relevant to Chronic Conditions Management
Able to establish good working relationships with internal and external stakeholders
Able to work effectively as an autonomous practitioner and member of a team to achieve outcomes and deadlines
Able to prioritise and manage service workload, balancing short term unpredictable demands with long term objectives
Good IT skills and understanding of General Practice computer systems
DESIRABLE
Ability to speak Welsh
Change Management, Service Improvement experience
Experience of implementing protocols and clinical guidelines
Audit experience
METHOD OF ASSESSMENT: Application form and Interview
Values
ESSENTIAL
Shows empathy and compassion towards others. Sees and treats others as individuals.
Treats people with dignity and respect.
Shows resilience, adaptability and flexible approach as situations arise and positivity when times are tough.
Shows respect for others’ views and appreciate others’ inputs and encourage colleagues to display our values.
Motivated to use initiative to recognise problems and seek solutions whilst understanding the importance of empowering and enabling others (patients, families, colleagues).
Friendly and helpful disposition, awareness of how our own and others’ behaviours impact on people’s experiences and the organisation’s reputation.
Willing to seek out learning, give and accept constructive feedback and committed to continuous improvement.
Consistently exhibits a positive attitude and respect for others.
Evidence of drive, enthusiasm and commitment.
Displays a positive and constructive attitude
METHOD Application Form, Interview, References
Other
Ability to travel within geographical area to meet the needs of this role.
Able to work hours flexibly when needed.
Application form and interview
GENERAL REQUIREMENTS
ØValues: All employees of the Health Board are required to demonstrate and embed the Values and Behaviour Statements in order for them to become an integral part of the post holder’s working life and to embed the principles into the culture of the organisation.
Ø Registered Health Professional: All employees who are required to register with a professional body, to enable them to practice within their profession, are required to comply with their code of conduct and requirements of their professional registration.
Ø Competence: At no time should the post holder work outside their defined level of competence. If there are concerns regarding this, the post holder should immediately discuss them with their Manager/Supervisor. Employees have a responsibility to inform their Manager/Supervisor if they doubt their own competence to perform a duty.
Ø Performance Appraisal: We are committed to developing our staff and you are responsible for participating in an Annual Performance Development Review of the post.
Ø Health & Safety: All employees of the organisation have a statutory duty of care for their own personal safety and that of others who may be affected by their acts or omissions. The post holder is required to co-operate with management to enable the organisation to meet its own legal duties and to report any hazardous situations or defective equipment. The post holder must adhere to the organisation’s Risk Management, Health and Safety and associate policies.
Ø Risk Management: It is a standard element of the role and responsibility of all staff of the organisation that they fulfil a proactive role towards the management of risk in all of their actions. This entails the risk assessment of all situations, the taking of appropriate actions and reporting of all incidents, near misses and hazards.
Ø Information Governance: The post holder must at all times be aware of the importance of maintaining confidentiality and security of information gained during the course of their duties. This will in many cases include access to personal information relating to service users.
Ø Data Protection: The post holder must treat all information, whether corporate, staff or patient information, in a discreet and confidential manner in accordance with the provisions of the General Data Protection Legislationand Organisational Policy. Any breach of such confidentiality is considered a serious disciplinary offence, which is liable to dismissal and / or prosecution under current statutory legislation and the HB or Trust Disciplinary Policy.
Ø Records Management: As an employee of this organisation, the post holder is legally responsible for
all records that they gather, create or use as part of their work within the organisation (including
patient health, staff health or injury, financial, personal and administrative), whether paper based or
on computer. All such records are considered public records and the post holder has a legal duty of confidence to service users (even after an employee has left the organisation). The post holder should consult their manager if they have any doubt as to the correct management of records with which they work.
Ø Dignity at Work: The organisation condemns all forms of bullying and harassment and is actively seeking to promote a workplace where employees are treated fairly and with dignity and respect. All staff are requested to report any form of bullying and harassment to their Line Manager or to any Director of the organisation. Any inappropriate behaviour inside the workplace will not be tolerated and will be treated as a serious matter under the HB/Trust Disciplinary Policy.
Ø DBS Disclosure Check: In this role you will have direct contact with patients in the course of your normal duties. You will therefore be required to apply for a Criminal Record Bureau Enhance Disclosure Check as part of the Health Board’s pre-employment check procedure.
Ø Safeguarding Children and Adults at Risk: The organisation is committed to safeguarding children and adults at risk. All staff must therefore attend Safeguarding Children & Adult training and be aware of their responsibilities under the All Wales Procedures.
Ø Infection Control: The organisation is committed to meet its obligations to minimise infections.
All staff are responsible for protecting and safeguarding patients, service users, visitors and employees against the risk of acquiring healthcare associated infections. This responsibility includes being aware
of the content of and consistently observing Health Board/Trust Infection Prevention & Control Policies and Procedures.
Ø No Smoking: To give all patients, visitors and staff the best chance to be healthy, all Health Board sites, including buildings and grounds, are smoke free.
Flexibility Statement: This job description is not intended to be exhaustive and it is likely that duties may be altered from time to time in light of changing circumstances, working environments and redeployment tasks. The job description will be reviewed periodically to take into account changes and developments in service requirements. Changes to this job description will be in consultation with the post holder.
Pay: £40,559.00-£48,841.00 per year
Benefits:
- Company pension
- Employee discount
- Free flu jabs
- Sick pay
Work Location: Hybrid remote in Swansea (Swansea)
