Frailty NurseNHS

Job summary

You will be working for all of the Practices in Weymouth and Portland PCN - The Bridges Medical Centre, Dorchester Road surgery, Cross Road Surgery, Wyke Regis & Lanehouse Medical Practice, Royal Manor Healthcare, Royal Crescent & Preston Road Surgery.

The Weymouth and Portland practices have a well established Frailty team which has been expanding since April 2015 to provide proactive holistic care for complex frail patients who are living in care homes or housebound and has also established an Ageing Well Clinic in 2022.This team is led by a General Practitioner and has a team of Frailty Practitioners who are Nurses, Advanced Clinical Practitioners, paramedics, Occupational Therapist and are supported by a Frailty Care Coordinator and 2 Frailty Health Care Assistants. There is a focus on ongoing case finding using risk profiling measures (EFI) and population health management (DiiS)

Main duties of the job

The main aims of the service are to:

• Deliver EHCH (enhanced health in care homes)
• Provide proactive, routine assessments based on a Comprehensive Geriatric Assessment to patients living in their own homes
• To make timely referrals to the wider multi-professional team to improve overall wellbeing reduce risk of falls, reduce risk of deterioration and reduce risk of hospital admission.
• To complete Personalised Care and Support Plans, focusing on what matters most to the patient
• To proactively identify patients who would benefit from a holistic assessment
• To support Ageing Well in the community, with a focus on reducing the progression of frailty / reversing this where possible
• To assess patient who have been re-referred with frailty related decline
• Effective team work to ensure the right patient is seen by the right staff member at the right time

Job description

Job Purpose / Clinical responsibilities

Based on an integrated approach, the Frailty Nurse will join the existing team, working to improve care for patients living with Frailty in the community.

Housebound patients, or those who are best assessed in their own homes:

• An integral member of the WECS team
• Home visits to identified patients to complete baseline assessments using an agreed proforma on a structured template to include (but not exclusively) continence, skin, nutritional status, care needs and unmet needs.
• Collection of basic observations
• ECG and phlebotomy
• A combination of new visits and follow up visits
• Make referrals to the wider MDT (including third sector) if and when appropriate
• Contribute to Multi-disciplinary discussions in order to support the patients care and support
• Support with comprehensive data collection
• Contribute towards completion of parts of the Dorset Care Plan

Other:

• Attendance at MDT meetings if requested to do so
• Comprehensive record keeping on SystmOne, using bespoke templates
• Ensure work emails are regularly accessed
• Ensure work mobile is carried at all times and that messages are picked up at regular intervals through the working day
• Manage workload effectively and ensure that sufficiently detailed contemporaneous notes are kept at all times.

About us

Two Harbours Healthcare is a not for profit organisation led by local General Practices in Weymouth and Portland. Our goal is to work more closely together (and with stakeholders) to share expertise, resources and provide services for the NHS.