Frailty NurseNHS

Job summary

An exciting opportunity has been presented for an experienced clinician to join our Frailty team at DGS Health. The role will require the individual to work, collaboratively, build relationships and work as part of a multi-disciplinary team to provide safe, high quality care.

Working within our Frailty Team offers both variety and flexibility, in terms of your day to day work, training and development, career progression.

Main duties of the job

The fundamental role of the post holder is to meet the primary care needs of an identified group of people identified as frail and needing further support in the community. The post holder will liaise with other community health and social care providers to meet the identified needs of these patients. This workload will involve reviewing medical issues and current problems, completing medication reviews and dementia screening, developing a treatment escalation plan, ensuring all appropriate assessments are completed and developing and implementing an appropriate individualised plan of care.

The service is designed to achieve the following:

• A fall in ambulance hospital journeys required by residents of the boroughs of Dartford, Gravesham and Swanley who are deemed as frail
• A drop in hospital attendances for these residents
• A reduction in hospital admissions for these residents
• Improved Health and social care support for these residents and their carers to help them to keep at home and avoid hospital admission.
• Joined up pathways with acute trust, ambulance service, community services, social services, community voluntary services and end of life care to support admission avoidance.

Please note you will be required to drive across the Dartford, Gravesham and Swanley area so a clean UK driving license is required.

Job description

Main Duties and Responsibilities

Clinical Responsibilities

• To assess, plan, implement and evaluate specialist treatment and care through personalised care plans to people on an allocated caseload; promoting independence and autonomy; working within a multi-disciplinary team.
• Supporting the GP in improving diagnosis and screening of people with dementia within the care home, this will be by the review of all care home residents.
• Advance own clinical knowledge, skill and competence based on current evidence through advanced educational programmes.
• Completing and sharing advanced care plans
• Partnership working with other providers to deliver seamless joined up care.
• Reviewing and making clinical decisions, including prioritisation of need.
• Provide highly specialist advice to others regarding the management and care of patients/service users.
• To demonstrate clinical effectiveness by use of evidence-based practice and outcome measures.
• Plan, implement and review health improvement programmes in a range of settings.
• Recognise, assess, and manage risk across the immediate and wider working environment and make appropriate decisions autonomously, ensuring statutory requirements are met.
• To be responsible for patient safety through knowledge of systems, legal requirements and understanding of litigation.
• To communicate effectively in verbal and written form in the exchange of highly complex, sensitive or contentious information in difficult situations using de-escalation, mediation, resolution and professional Duty of Candour.
• To evaluate care, taking appropriate action leading to improvement in quality standards through clinical audit, root cause analysis and dealing with complaints.
• Provision of support to carers considering what can put in place to support that persons mental health and wellbeing, by the use of tools to identify deterioration in wellbeing and mental state.
• Liaison between local organisations such as volunteering etc to provide services that can support the delivery of care within the patients own home.
• Referral to and attendance at MDTs involving a range of health and care professionals, from one or more organisations, working together to deliver comprehensive patient care. The benefits of such an approach can include improved health outcomes, enhanced satisfaction for the individual and a more efficient use of resources.

About us

DGS Health is a GP Federation based in Gravesend, North Kent. We are comprised of 100% of local GP practices across Dartford, Gravesham and Swanley. We pride ourselves on being clinically led and managerially enabled and like to ensure we recruit people who share our ethos and culture. We are a small and friendly but growing organisation, employing around 40 people across a range of roles. Our services include urgent treatment services, paramedic home visiting, care home support, frailty nursing, pharmacy services to name a few. We employ a diverse range of roles including GPs, nurses, administrators, managers, HCAs and paramedics.