Frailty NurseNHS

Job summary

We are looking for an experienced Nurse with a background in frailty to join our innovative Ageing Well Team across the PCN. The post holder will provide proactive, person-centered care for people living with moderate and severe frailty, including undertaking and coordinating Comprehensive Geriatric Assessments (CGA) to identify medical, functional, psychological and social needs and agree individualised care plans.

This is an exciting opportunity for an enthusiastic, motivated Registered Nurse, working closely with our O/T, physio & care coordinators to provide proactive care for the moderately and severely frail. This role is integral to the assessment and management of patients living with frailty to allow the best access to care and support. You will be an autonomous practitioner who is adaptable, has a flexible can-do attitude with a passion for excellence & ability to work well both on their own & as part of a team.

This is a community-based role applicants must have a full driving license & access to a vehicle daily.

Main duties of the job

The successful candidate should be an experienced practitioner who will work in partnership with other health professionals in supporting frail patients and providing holistic patient care. They will act within their professional boundaries and competencies, assessing, planning, implementing and evaluating patient care.

They will participate in MDT meetings to discuss patients that the Ageing Well Team are supporting. As a result, they must have high level communication/interpersonal skills to negotiate & establish collaborative partnerships with patients & care professionals and have enthusiasm & the ability to use their own initiative.

Job description

KEY RESPONSIBILTIES

To visit clients who meet the Frailty assessment criteria within their usual place of residence.

To assess and identify the health needs of patients who are frail and who may have long-term conditions.

To undertake and coordinate Comprehensive Geriatric Assessments (CGA), within professional competence, covering physical health, medicines, cognition, mood, mobility, falls risk, nutrition, continence, functional ability, social circumstances and future care wishes.

To use CGA findings to develop, document and review person-centered, strengths-based care and support plans with patients, carers and the multidisciplinary team, escalating clinical concerns appropriately.

To provide clinical leadership, guidance and support to care coordinators, including advice on patient care, risk management, escalation and effective multidisciplinary working within agreed professional boundaries.

To assess, plan, implement and evaluate programmes of care to address the identified needs of patients identified as being frail and/or those with long-term conditions.

To support the development of patients individual Personalised Care and Support Plans.

Develop disease specific patient information and education to support patients self care.

Participate in education & staff development, including specialised CPD relevant to Frailty and Dementia and actively participate in regular supervision.

Please see attached job description for full details of the role.

About us

Employed by Selby Prime Care Ltd but subcontracted to Selby Town PCN, this is a role to support patients across Selby Town PCN.

The PCN works over four practice sites (Beech Tree Surgery, Escrick Surgery, Posterngate Surgery and Scott Road Medical Centre) a local voluntary sector site & our local community hospital.

The PCN has a Clinical Director, two Clinical Lead GPs and is managed by the PCN Operations Manager & Business Manager. We work in increasingly collaborative partnerships across several workstreams, which include important priority areas of mental health, frailty, urgent care and health inequalities. Our team consists of a diverse multi-professional workforce which includes pharmacists, MSK practitioners, mental health workers, care coordinators, social prescribing link workers, a frailty therapy team, an urgent care coordinator, UCPs, paramedics, ACPs, a transformational lead, a digital lead, health & wellbeing coach.