Job Description

###

NHS AfC: Band 7

Main area

Surrey Downs Health & Care

Grade

NHS AfC: Band 7

Contract

Permanent

Hours

Full time - 37.5 hours per week

Job ref

343-SDH&C-7238997

Site

Leatherhead PCN

Town

Leatherhead

Salary

48,270 - 54,931 Pro Rata Per Annum Inc Fringe HCAS

Salary period

Yearly

Closing

12/06/2025 23:59
###

Job overview

Surrey Downs Health & Care

This is an exciting and innovative role which will involve working alongside community GPs, paramedics, pharmacists, district nurses, adult social care, voluntary organisations and community matrons to support the delivery of proactive healthcare and support to people living with frailty, multiple long-term conditions and/or complex needs to help them stay independent and healthy for as long as possible at home.



If you're looking for an employer that is working to push beyond and remove traditional boundaries and barriers, bringing care to patients when and where they need it, and you want to work alongside motivated, passionate, and visionary colleagues, come and work for Surrey Downs Health and Care!


###

Main duties of the job

Take clinical responsibility for the patient and work collaboratively with all professionals, carers and relatives to gain a deep understanding of all aspects of the patient's physical, emotional and social situation. Conduct physical examination and detailed history taking, diagnosis and treatment planning. Develop a personalised care plan for the patient based on the full assessment of medical, nursing and care needs. This includes preventative measures and anticipation of future health needs. Plan, implement, monitor and review therapeutic interventions with individuals who have a long term condition and their carers.
Be competent or become competent in using the Comprehensive Geriatric assessment when assessing patients ensuring all patients over the age of 65 are Rockwood scored.
Use relevant nursing assessment tools to ensure best practice is achieved Use EMIS CM template to complete assessments. Be competent or become competent in advanced care planning on an individual basis with the patient and be competent in the completion of a RESPECT form if relevant. Enable individuals with long term conditions to manage their medicines and their conditions independently Co-ordinate and review the delivery of care plans to meet the needs of individuals with long term conditions or complex needs

###

Working for our organisation

Surrey Downs Health and Care deliver care closer to people's own communities through our Primary Care Networks, Community Hospitals, Specialist Services and our innovative partnership of local NHS organisations.



Surrey Downs Health and Care has a track record of providing person centered care that goes beyond organisational boundaries to do what is best for the individual. This partnership includes:


The three GP federations GP Health Partners, Dorking Health representing practices that operate in the Surrey Downs area CSH Surrey Epsom and St Helier's University Hospitals NHS Trust Surrey Council County

Historically, there have been boundary lines between the organisations that provide care to people in their homes, in GP surgeries and in hospitals, but we have always been united in our mission to provide great care to the people who need us.



It's on those grounds that the Surrey Downs Health and Care was formed - we want local people to receive the care that they need in the right environment. By bringing together our expertise, we can improve patient care and enable local people to access the right support, care and treatment more easily than ever before.



In bringing this partnership together, we are working to the same set of values that will translate into better care for our residents.


###

Detailed job description and main responsibilities

Enable individuals with long term conditions to manage their medicines and their conditions independently Co-ordinate and review the delivery of care plans to meet the needs of individuals with long term conditions or complex needs Develop risk management plans to support individuals' independence and daily living within their home Lead on frailty and coordinate the monthly frailty meeting with the frailty consultant, BICS GP and the wider MDT Work closely with the Frailty Care Coordinator to ensure all data required is captured from the frailty meeting Use and develop methods and systems to communicate, record and report Present individuals needs and preferences Procure services for individuals Manage the use of physical resources Support the protection of individuals, key people and others Develop practices which promote choice, well-being and protection of all individuals Assess the health care needs of individuals with long term conditions and agree care plans Enable individuals with long term conditions to make informed choices concerning their health and well-being Support individuals to live at home safely and as independently as possible Build a partnership between the team, patient and carers Build partnerships with the local services to Banstead being proactive in your approach around early interventions. Work very closely with the Care Coordinators within the proactive team to ensure that all needs are met i.e. social, emotional, loneliness Promote, monitor and maintain health, safety and security in the working environment (Including use of risk assessments) Identify mental health needs and/or other health related issues Refer individuals to mental health and / or other services Contribute to the assessment of needs and the planning, evaluation, and review of individualised care plans of patients Implement specific parts of personlised care plan using a comprehensive geriatric assessment Enable patients to access psychological support Empower families, carers and others to support individuals with long term conditions Empower individuals with long term conditions to represent their view and organise their own support, assistance and action Help individuals with long term conditions to change their behavior to reduce the risk of complications and improve their quality of life Assist individuals to evaluate and contact support networks Enable people with long term conditions to cope with changes to their health and well-being Provide clinical leadership and take responsibility for the continuing professional development of self and others (including a mentorship role) Promote the values and principles underpinning best practice and share best practice Develop, sustain and evaluate collaborative work with others

Please refer to the and Person specification for more details.


###

Person specification

####

Essential

#####

Essential criteria

Professional Registration Previous experience in community setting #####

Desirable criteria

Understanding of Proactive Care Process Ability to work in MDT environment ####

Desirable

#####

Essential criteria

Previous experience in community role #####

Desirable criteria

Able to work in MDT environment ###

Employer certification / accreditation badges

###

Applicant requirements

You must have appropriate UK professional registration.


This post is subject to the Rehabilitation of Offenders Act 1974 (Exceptions) Order 1975 (Amendment) (England and Wales) Order 2020 and it will be necessary for a submission for Disclosure to be made to the Disclosure and Barring Service.