Job Description

Join Us at Cross Gates PCN

Are you a highly motivated and forward-thinking nurse passionate about proactive, person-centred care?

Cross Gates Primary Care Network (PCN) offers an exciting opportunity to be part of a dynamic, multidisciplinary team delivering innovative and integrated healthcare to our vibrant East Leeds community.

The Opportunity

At Cross Gates PCN, you will be joining a well-established collaboration of four practices operating across seven sites: Ashfield and The Grange Medical Centre, Colton Mill and The Grange Medical Centre, Family Doctors, and Manston Surgery serving over 32,000 patients, including those in five care homes. You will be central to our mission of preventative and personalised care, helping to reduce health inequalities and support people to live independently for longer.

We are proud to foster a culture where clinical leadership, professional growth, and collaborative working thrive. You will work alongside a rich and diverse multidisciplinary team, including clinical pharmacists, pharmacy technicians, mental health practitioners, ACPs, physician associates, physiotherapists, care coordinators, and social prescribers, all dedicated to delivering holistic, coordinated care.

Why Choose Cross Gates PCN?

oA Culture of Innovation: We are proud of our proactive approach in adopting new models of care and adapting digital solutions that enhance patient experience and staff wellbeing including a Respiratory Pilot, Dementia Specialist Nurse Service, Lipid Optimisation, East Leeds Collaborative Health Bus and drive through vaccine clinics, Weight Management Specialist Service, General Practice Improvement Programme and a Frailty and Enhanced Care Home Service.

oIntegrated Neighbourhood Working: Collaborate closely with community teams, Cross Gates Local Care Partnership and voluntary partners including Linking Leeds, memory support workers, neighbourhood teams, and Cross Gates Good Neighbours to deliver holistic care.

oCareer Development: We invest in our nursing workforce through ongoing training, peer support, clinical supervision and leadership opportunities within areas such as frailty, long-term condition management, anticipatory care, and quality improvement.

oReal Impact: This is your chance to make a tangible difference in people's lives in our community especially those living with complex health needs while helping shape the future of proactive, community-based care.

oStrong Nursing Support and Leadership: In addition to working alongside a wide range of health professionals, you will benefit from dedicated nursing leadership and peer support. This includes access to the clinical director, nurse associates, specialist nurses, and advanced nurse practitioners, ensuring you are clinically supported and professionally empowered at every stage of your role.

Job Summary

We are seeking a Specialist Proactive Care Nurse - a registered adult nurse who will work closely with GPs, Primary and Community Nursing Teams, Care Coordinators, Allied Health Professionals, and Neighbourhood Teams to deliver targeted interventions, particularly for people living with frailty, multimorbidity, or complex care needs.

As a Specialist Proactive Care Nurse, you will be instrumental in shaping and delivering innovative, preventative, and personalised models of care that align with the NHS Long Term Plan and the principles of integrated neighbourhood working. Your core responsibilities will include:

oProactive Case Finding and Population Health Management Utilise population health data, clinical judgement, and multidisciplinary input to identify individuals at high risk of deterioration, unplanned admission, or loss of independence. Proactively address social, clinical, and environmental factors influencing health, focusing on frailty, multimorbidity, and complex needs.

oAnticipatory and Personalised Care Planning Lead the development of holistic, person-centred care plans with patients, carers, and the wider neighbourhood team. Ensure plans reflect individual priorities and include shared decision-making, preventative actions, and escalation planning.

oPrevention, Screening, and Health Promotion Deliver targeted screening, lifestyle advice, and health coaching that promote self-management and reduce risk of deterioration. Support outreach and public health efforts tackling inequalities and improving neighbourhood wellbeing.

oIntegrated Working and Care Coordination Participate in multi-agency team meetings and neighbourhood huddles to coordinate timely care across primary care, social care, community health, and the voluntary sector. Act as a clinical resource and patient advocate.

oAvoiding Unnecessary Hospital Admissions Implement early intervention and crisis prevention strategies to support people remaining at home when safe. Provide clinical input and leadership in community alternatives to hospital, including enhanced case management and rapid response.

oClinical Leadership and Quality Improvement Contribute to service development, audit, and improvement initiatives that strengthen proactive care. Support the use of evidence, digital tools, and innovation in practice aligned with the NHS Long Term Plan.

Outline of the post

The post main functions but not exhaustive:

Proactive & Preventative Clinical Care

oAnticipatory and Person-Centred Care Planning: Working closely with the Frailty Team, you will lead and support the delivery of anticipatory care planning for individuals at risk of hospital admission, particularly those living with frailty, complex needs, or long-term conditions. Develop and monitor personalised care plans that reflect patient goals, preferences, and clinical needs.

oEarly Identification and Clinical Reviews: Support the early identification of patients with deteriorating health through regular case-finding and clinical reviews, using tools such as the Frailty Index, Q-Risk, and professional judgement to inform proactive interventions.

oComprehensive Holistic Assessment: Undertake thorough clinical assessments that consider physical, psychological, and social dimensions of care, supporting the delivery of safe, individualised, and effective treatment.

oSupporting Self-Management and Independence: Coordinate and deliver interventions that promote self-management, resilience, and independence, enabling patients to take an active role in their health and care planning.

oCommunity-Based Care Delivery: Conduct regular clinical reviews in clinic settings and provide home visits for housebound patients or those residing in care homes, ensuring continuity and equity of access.

oHealth Promotion and Prevention: Deliver education, support, and interventions related to disease prevention, lifestyle modification, and health promotion. Engage with patients and communities to raise awareness of key public health messages.

oScreening and Vaccination Participation: Participate in seasonal vaccination programmes, NHS screening initiatives, and health surveillance campaigns, ensuring timely uptake and follow-up where needed.

oChronic Disease Monitoring and Support: Provide clinical care and monitoring for patients with chronic conditions including diabetes, hypertension, chronic kidney disease, respiratory illnesses, and cardiovascular disease. Tailor interventions to meet individual clinical and lifestyle needs.

oCollaborative Clinical Management: Work closely with GPs, practice teams, and specialist services to optimise long-term condition management, reduce complications, and minimise hospital admissions.

oEvidence-Based Practice: Utilise clinical protocols, national guidelines, and best practice frameworks to deliver safe, effective, and personalised long-term care.

Multidisciplinary Team Engagement: Actively participate in multidisciplinary team (MDT) meetings to discuss complex patient cases and ensure interventions are aligned across health and care services.

oIntegrated Referrals and Liaison: Refer and liaise with community teams, social care, and voluntary sector services to deliver holistic, joined-up care tailored to the patient's social and medical needs.

oContinuity and Coordination: Serve as a key point of contact for patients, carers, and external providers involved in individual care plans, ensuring seamless communication and continuity of care.

Leadership and Professional Responsibilities

oClinical Leadership and Role Modelling: Provide clinical guidance and support to junior members of the nursing team, acting as a positive role model to motivate, empower, and inspire through effective leadership. Serve as a mentor and clinical resource for students and less experienced staff.

oFostering a Learning Culture: Promote the workplace as a supportive learning environment by encouraging reflective practice, shared learning, and adoption of external best practice across the multidisciplinary team.

oClinical Leadership in Specialist Areas: Lead on designated areas of clinical interest, such as frailty, chronic disease management, falls prevention, or patient activation, contributing specialist knowledge to shape care delivery and service priorities.

oService Development and Pathway Design: Support the development and implementation of proactive care pathways and actively contribute to service redesign efforts that enhance integration, efficiency, and patient outcomes.

oProfessional Development and Supervision: Take ownership of your own learning and professional development, including engaging in clinical supervision, reflective practice, and skills development relevant to role and scope.

oQuality Improvement Participation: Contribute to quality improvement work through active participation in audits, service evaluations, and initiatives aimed at raising standards of care and operational excellence.

oResource and Materials Management: Maintain and ensure the availability of relevant nursing materials and resources across practices, including patient education leaflets, posters, and clinical templates.

oAppraisal and Revalidation: Provide evidence of ongoing continuing professional development (CPD) through participation in annual appraisals, portfolio building, and NMC revalidation processes.

oMeeting Participation and Representation: Attend and contribute to practice, PCN, and local network meetings to share knowledge, influence service development, and ensure nursing perspectives are represented in wider planning and decision-making.

Quality Services

oMulti-Agency Collaboration: Work effectively with colleagues and professionals from other agencies to meet the holistic needs of patients and their carers, ensuring coordinated and responsive care.

oTime and Resource Management: Manage your time, workload, and resources efficiently to maintain a high standard of care and service delivery, contributing to a culture of quality and accountability.

oProfessional Standards and Regulation: Operate within your professional scope and NMC Code of Conduct, recognising the boundaries of your competence and seeking guidance or escalation when appropriate.

oAccurate Record Keeping: Maintain accurate, contemporaneous, and comprehensive clinical records in line with legal, regulatory, and organisational policies, using appropriate clinical systems.

oEvidence-Based Practice: Deliver care that is informed by local and national guidelines, best practice standards, and the latest clinical evidence to ensure safe, effective, and person-centred outcomes.

oPerformance Evaluation: Regularly assess your own clinical performance through self-reflection, peer review, benchmarking, and formal feedback mechanisms, acting on findings to support ongoing improvement.

oQuality Improvement and Service Development: Identify and contribute to service development and quality improvement initiatives within the practice, PCN, and neighbourhood, responding to the evolving needs of the population.

oClinical Audit and Outcome Monitoring: Participate in audits to evaluate individual and team performance, implementing changes and recommendations that enhance clinical quality and operational effectiveness.

oSystem-Wide Improvement Collaboration: Work in partnership with other clinical teams to improve healthcare quality across the wider system, responding to local and national priorities, policy changes, and population health needs.

oPatient Outcome Evaluation: Continuously evaluate patients' responses to care and assess the effectiveness of interventions, using outcomes to inform ongoing care planning and service refinement.

oShared Learning and Knowledge Exchange: Engage in and support shared learning opportunities across primary care and the wider health and care system, promoting a culture of continuous improvement.

oLearning from Incidents and Complaints: Use structured approaches (e.g., root-cause analysis) to reflect on and learn from patient complaints, incidents, or near misses, including those involving junior colleagues, to improve safety and practice.

oSafeguarding and Legal Awareness: Demonstrate an understanding of legal frameworks and safeguarding procedures to identify, support, and refer vulnerable adults or those at risk of abuse, in line with local and statutory guidance.

oSupport for At-Risk Individuals: Provide guidance and appropriate referrals for individuals affected by domestic abuse, substance misuse, or other safeguarding concerns, acting with sensitivity and in accordance with professional standards.

Communication

oPerson-Centred and Inclusive Communication: Utilise sensitive and person-centred communication styles to ensure patients are fully informed and able to consent to treatment. Adapt communication methods to meet varying levels of understanding, cultural backgrounds, language needs, and preferred formats.

oSupporting Patients Through Difficult Conversations: Communicate empathetically and effectively with patients and carers when delivering potentially distressing or complex information, offering emotional support and reassurance where needed.

oPromoting Adherence and Understanding: Use communication strategies to support patients in understanding and adhering to prescribed treatments, encouraging shared decision-making and self-management.

oCollaborative Communication Across the PCN: Establish and maintain effective communication with individuals, teams, and wider stakeholders across the PCN, practice, and neighbourhood settings, both verbally and in writing.

oAdvocacy and Representation: Act as an advocate for patients and colleagues, ensuring their views, concerns, and choices are heard and considered in clinical discussions and service planning.

oClinical Information Sharing: Communicate patient health status clearly and accurately using appropriate clinical language, tools, and technology, ensuring that information is timely and accessible to relevant professionals.

oSignposting and Patient Support: Remain aware of local services and support options (e.g., PALS, social prescribing) and provide patients with accessible, appropriate information. Recognise when to refer patients for additional support.

oReflective Communication Practice: Continuously reflect on personal communication style and patient feedback as part of professional development, appraisal, and revalidation processes.

oDigital and Non-Verbal Communication: Use digital communication tools effectively, including email, messaging platforms, Microsoft Teams, and electronic task systems, to collaborate and share information securely within the team.

oRecord Keeping and Information Governance: Maintain accurate, timely, and confidential patient records using appropriate IT systems, in line with Caldicott principles and data protection standards.

oEngagement in MDT and Virtual Meetings: Actively participate in multidisciplinary team (MDT) meetings, both in person and via digital platforms such as Microsoft Teams or other clinical communication systems.

Education, Development and Professional Growth

oStudent Training and Mentorship: As a Primary Care Network (PCN) with Advanced Training Practices, you will contribute to the training, supervision, and development of nursing and healthcare students during placements within the practice, PCN, and Neighbourhood Team.

oContinual Professional Development: Maintain and enhance your professional competence by staying up to date with clinical evidence, therapeutic advancements, national policy, service changes, and relevant legislation--particularly relating to pharmacist competencies and practice frameworks.

oService Development and Innovation: Identify and lead on areas for development and improvement across the PCN, individual practices, and Neighbourhood working models, supporting service evolution in response to patient and population needs.

oKnowledge Sharing: Disseminate learning from courses, conferences, and current evidence to team members to promote best practice and keep the multidisciplinary team informed of new developments and innovations.

oSelf-Directed Learning: Regularly assess your own learning needs and undertake appropriate training and development activities as part of your ongoing professional development and appraisal process.

oEducation and Health Promotion: Provide educational support to patients, carers, families, and colleagues, fostering a culture of learning and empowerment in all interactions and settings.

oTraining and Compliance: Complete all mandatory training and actively participate in scheduled TARGET sessions, PCN or neighbourhood learning events, and in-house training to ensure compliance and continuous professional growth.

oProfessional Engagement: Attend relevant nursing conferences and professional events as appropriate to maintain clinical expertise and share insights with the wider team.

Research and Innovation

As a specialist proactive care nurse working, you will play a key role in driving forward the NHS commitment to embedding research and innovation into everyday practice as outlined in the NHS Long Term Plan. This will include:

oPromoting a Culture of Evidence-Based Practice: Champion the use of current evidence to inform clinical decisions, supporting best outcomes for individuals with complex or long-term health needs in community and neighbourhood settings.

oEngaging in Research Activity: Actively contribute to the design, delivery, or dissemination of local and national research projects relevant to proactive and preventative care. This includes identifying eligible patients, obtaining consent, collecting data, and collaborating with research leads or academic partners.

oSupporting Integrated Neighbourhood Teams: Contribute to shared learning and reflective practice within integrated multidisciplinary teams, ensuring that research outcomes are translated into improvements in population health and health inequalities at neighbourhood level.

oQuality Improvement and Innovation: Take a leadership role in initiating or supporting service evaluation, audits, and quality improvement projects, with a focus on anticipatory care, early intervention, and personalised care planning.

oBuilding Capacity and Capability: Support the development of junior staff and students in understanding the importance of research and innovation in clinical care. Act as a role model and mentor for evidence-based practice within the team.

oPartnership Working: Engage with Primary Care Networks, local authorities, voluntary sector organisations and academic partners to support neighbourhood-level research priorities and integrated service models that improve care across pathways.

Job Types: Full-time, Part-time

Pay: 38,682.00-50,273.00 per year

Expected hours: 30 - 37.5 per week

Benefits:

Company pension
Work Location: In person

Application deadline: 04/08/2025