Long-Term Conditions Registered Nurse


Company:	NHS Jobs
Salary:	Negotiable
Hours:	Full-time
Location:	Belper, DE56 1AY
Job type:	Permanent
Posting date:	12 Oct 2026
Closing date:	31 Oct 2026

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Summary

Primary Responsibilities Manage an agreed waiting list of adults with single or multiple long-term conditions, prioritising people at risk of deterioration, avoidable admission or health inequality. Undertake comprehensive holistic assessments in patients homes and care homes, including physical health, mental wellbeing, frailty, function, cognition, medicines, nutrition, falls risk, social circumstances, carer needs and safeguarding. Complete structured long-term condition reviews within competence, including conditions such as diabetes, cardiovascular disease, hypertension, respiratory disease and frailty, using current NICE guidance and local pathways. Develop, implement and evaluate personalised care and support plans with patients, carers and relevant professionals, including agreed goals, self-management support, escalation arrangements and advance care planning where appropriate. Identify early deterioration or red flags, initiate immediate care within scope of practice and escalate promptly to the responsible GP, emergency services, urgent community response or other appropriate service. Undertake and interpret relevant clinical observations and point-of-care or diagnostic tests within competence and service protocols. Support medicines optimisation through reconciliation, adherence review, side-effect monitoring and timely referral to a GP, clinical pharmacist or independent prescriber. Provide immunisation, health promotion, prevention and supported self-management interventions where trained, authorised and clinically appropriate. Make timely referrals and coordinate care across primary care, community nursing, specialist teams, pharmacy, therapy, mental health, adult social care, care homes, voluntary services, urgent community response and virtual wards. Ensure that the patient and carer understand the care plan, who to contact and when to seek further help. Multidisciplinary and Neighbourhood Working Work as an integral member of the Belper PCN Home Visiting Service, collaborating with GPs, advanced clinical practitioners, nurses, nursing associates, pharmacists, care coordinators, social prescribers and other professionals. Participate in clinical huddles, multidisciplinary meetings, care home discussions and case reviews, contributing nursing expertise and coordinated plans. Liaise with the patients registered practice and named clinician to maintain continuity, clear accountability and timely follow-up. Promote a no wrong door approach by helping patients and professionals navigate the most appropriate local support. Build effective relationships with neighbourhood partners and contribute to service integration, pathway development and joint learning. Population Health, Prevention and Digital Practice Use PCN data, clinical registers and risk-stratification processes to help identify people who would benefit from proactive intervention, in accordance with information governance requirements. Address modifiable risk factors, support vaccination and screening uptake, encourage rehabilitation and self-management, and signpost to local community resources. Recognise barriers associated with deprivation, rurality, disability, cognition, language, caring responsibilities or digital exclusion; make reasonable adjustments and advocate for equitable access. Use approved digital systems, remote monitoring and communication tools to improve continuity and efficiency while retaining face-to-face care where clinically required or preferred. Record accurate, contemporaneous and appropriately coded information in the shared electronic patient record and support agreed outcome reporting. Clinical Governance and Professional Practice Practise within the Nursing and Midwifery Council Code, professional competence, indemnity arrangements, legislation, NICE guidance and Belper PCN policies. Maintain professional registration, mandatory training and an evidence-based portfolio; participate in appraisal, clinical supervision and continuing professional development. Obtain valid consent, assess capacity where relevant and uphold confidentiality, dignity, equality and patient choice. Follow safeguarding, infection prevention and control, medicines management, lone-working, chaperone, incident reporting and information governance procedures. Recognise the limits of competence, seek advice and escalate clinical uncertainty or risk to the designated senior clinician. Contribute to audit, quality improvement, patient-safety reviews, complaints learning, patient experience and service evaluation. Use equipment safely, maintain stock and report faults, risks or incidents promptly. Communication, Education and Leadership Communicate complex or sensitive information clearly and compassionately, adapting to individual communication needs and using interpreters or accessible formats when required. Provide education and coaching to patients, carers, care-home staff and colleagues on long-term condition management, prevention and recognition of deterioration. Support induction, peer learning and development of less experienced staff or students where appropriate. Act as a positive role model for person-centred, integrated and improvement-focused practice. Manage time and workload effectively, balancing planned proactive care with changing clinical priorities. Working Conditions and Role Requirements Regular travel across the Belper PCN area and work in patients homes, care homes and other community settings. Ability to work independently while maintaining reliable communication and access to clinical support. Exposure to unpredictable environments, distressing circumstances, infection risks and manual-handling considerations; all risks must be managed through policy and dynamic risk assessment. Flexibility to work within the service operating model, which may include extended hours subject to contract. Able to meet the travel requirements of the role; reasonable adjustments will be considered. Appointment is subject to satisfactory employment checks, occupational health clearance and the appropriate Enhanced DBS check. Key Working Relationships Patients, families and unpaid carers; Belper PCN practices; GPs and the Home Visiting Service team; community nursing and specialist long-term condition teams; urgent community response and virtual wards; pharmacists and pharmacy technicians; therapists; mental health services; adult social care; care homes; voluntary and community organisations; ambulance, NHS 111, out-of-hours and secondary care services.

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