PCN Frailty Team Nurse

Job responsibilities

Moderate and Severe Frailty

Case Identification:

Use eFI/ Personal Proactive Whiteboard to identify list of potential patients living with moderate or severe frailty, supported by sub-cohort analysis, with the aim of identifying the highest risk patients

Holistic Assessment:

Provide support to the Frailty Team Administrator to ensure the self-assessment questionnaire process is carried out effectively and to a high-quality standard

Triage potential patients to determine which will receive a comprehensive geriatric assessment (CGA)

Determine what action to take with those patients who do not receive a CGA and ensure those actions are undertaken

Undertake CGAs as determined for relevant patients, inputting information into the digital template and ensuring they are given a Rockwood Score. Draw in clinical support as required from the PCN Frailty Teams GP with an interest in Frailty for those patients with a higher acuity of need

Personalised Care and Support Planning:

Ensure a Personalised Care and Support Plan (PCSP) is produced and agreed with the relevant patient and any carer/family, along with a ReSPECT plan

Coordinated and Multi Professional Working:

Ensure close multi-professional and multi-agency working, especially with other members of the local Integrated Neighbourhood Team(s), to facilitate the delivery of each patients PCSP

Continuity of Care including reviews

Support the Care Coordinator to ensure regular review of patients take place as planned and agreed according to the individual needs of the person and /or following trigger events such as hospital admission

Dementia Co-diagnosis

Determine the frequency of MDT meetings, depending on demand; keep under regular review

Support the Frailty Team Administrator to ensure all post MDT meetings are carried out in a timely and effective manner

General

Leadership:

Provide leadership and support to the Care Coordinator and Frailty Team Administrator

Clinical Leadership: Provide clinical assessment, diagnosis, and case management of people living with frailty in the community using agreed standardised tools and templates. Responsible for frailty team care coordinators, frailty team administrators, managing caseloads and ensuring the appropriate allocation of personnel and tasks to team members

Partnership Working: Build and maintain effective working relationships with GPs, acute and community hospitals, Adult Social Care, voluntary sector organisations, and other community services to deliver integrated care

Care Coordination: Ensure seamless transitions of care and continuity through proactive case management and liaison with all relevant stakeholders

MDT Coordination: Lead and participate in MDT meetings, ensuring collaborative care planning and shared decision-making across system partners

Education and Training: Support the development of frailty awareness and skills for other practitioners, carers, and patients

Service Development: Contribute to the design, implementation, and evaluation of frailty pathways and services

Risk Management: Identify and manage clinical risks, including falls, polypharmacy, and cognitive decline

Patient Advocacy: Promote shared decision-making and ensure care aligns with patients values, goals and what matters to them

Data and Audit: Collect and analyse data to:

support risk stratification and segmentation of the patient cohort,

enable use of the Personalised Proactive Whiteboard for care coordination,

monitor outcomes and measure impact, support quality improvement and inform commissioning conversations

Other responsibilities

Applying PCN policies, standards and guidance;

Contributing to the teaching and training of trainees, new employees and employees who are undertaking training;

Awareness of and compliance with all relevant G DOC policies/guidelines for your role, e.g. prescribing, confidentiality, data protection, health and safety

Contributing to evaluation/audit and clinical standard setting within the organisation as applicable to your role;

Attending training, meetings and other meetings and events organised by the Practices, PCN, or other agencies such as the ICB, where appropriate;

Contributing to audits and written returns to ensure that the PCN meets quality standards and receives the designated funding, as appropriate to your role;

Treating colleagues with courtesy and respect;

Complying with G DOCs values, and the values of your PCN/team.

Confidentiality

Comply with the Confidentiality Agreement.

Health & Safety

Under the Health and Safety at Work Act 1974, you have a personal responsibility to have regard to your own and others safety.

You should familiarise yourself with fire exits at all sites where you work, and the action that you should take in the event of a fire.

Personal alarms are available from G DOC for all GPs, wherever you are working. Your site induction should cover local procedures for summoning external help. Please ensure you familiarise yourself with these local procedures.

You must comply with site Health and Safety procedures, including those that concern clinical waste, use of hazardous substances, and the use and disposal of sharps.

Health and safety hazards should be reported to the Practice Manager.

You should dress appropriately and professionally. To reduce the risk of sharps injuries, shoes should be closed (not open sandals).

You must ensure that your car is insured for commuting and home visits.

GPs in Gloucestershire have been the victims of serious & sustained stalking and violence. You should not give anyone outside the PCNinformation about when and where colleagues will be working. Refer any queries about rotas etc to the Practice Manager or G DOC. Be aware that stalkers may have knowledge of the local healthcare system and sound very plausible

Working conditions

Frequent, prolonged VDU use

Time-pressured environment

High levels of accuracy and attention to detail essential at all times

Exposure to distressing situations and written material

Safeguarding

Safeguarding is everyones responsibility. Even staff who do not routinely have contact with patients may become aware of a safeguarding concern. You will

Ensure you are familiar with G DOCs safeguarding procedures

Report all concerns promptly, following the safeguarding procedures

Ensure that you maintain an appropriate level of safeguarding training for your role

Contribute to meetings and other safeguarding processes, as appropriate to your role

Equality and Diversity

You will support the equality, diversity and rights of patients, carers and colleagues, to include:

Acting in a way that recognises the importance of peoples rights, interpreting them in a way that is consistent with PCN procedures and policies, and current legislation;

Respecting the privacy, dignity, needs and beliefs of patients, carers, and colleagues.

Quality and Patient Safety

You will strive to maintain quality within the PCN, and will:

Alert other team members to any concerns about clinical governance or quality and risk; participate in Significant Event Analysis reviews

Assess own performance and take accountability for own actions, either directly or under supervision;

Contribute to the effectiveness of the team by reflecting on own and team activities and making suggestions on ways to improve and enhance the teams performance;

Work effectively other agencies to meet patients needs;

Effectively manage own time, workload and resources.

Avoid working if you are impaired from doing so safely or effectively, for example due to illness.

If relevant to your role, ensure that any necessary handover and follow up arrangements for patients have been made.

Inform your line manager if you have concerns about a colleague that might affect patient safety

Inform your line manager of any complaints or significant events that have arisen from your work for G DOC.

Participate in investigations of any complaints or significant events, if asked to do so.

Inform your line manager immediately if you have been charged with any criminal offence.

If you are in a regulated profession (e.g. nurse, doctor, pharmacist, accountant).

Comply with your regulators guidance.

Inform your line manager immediately, if you are under investigation by your regulator.

Inform your line manager immediately, if you have any restrictions or conditions imposed on your practice by your regulator

Personal/Professional Development:

You will ensure that your mandatory training remains up to date.

You will participate in any training programme implemented by the PCN as part of this employment, such training to include:Participation in an annual individual performance review, including taking responsibility for maintaining a record of own personal and/or professional development

Taking responsibility for own development, learning and performance and demonstrating skills and activities to others who are undertaking similar work

Communication

You should recognise the importance of effective communication within the team and will strive to:

Communicate effectively with other team members, including through use of email, TeamNet and other agreed communication channels;

Checking your email and TeamNet every working day;

Communicate effectively with patients and carers;

Recognise peoples needs for alternative methods of communication and respond accordingly i.e. signing and use of telephone and face-to-face translators

Experience

Essential

• Minimum of 2 years post-registration experience

Desirable

• Broad knowledge of General Practice
• Experience of managing a team, including direct reports
• Experience of delivering contractual requirements e.g. KPIs, QOF

Personal qualities

Essential

• Clear, polite telephone manner
• Polite and confident
• Flexible and cooperative, motivated
• High levels of integrity and loyalty
• Demonstrates empathy, respect, and kindness in all interactions
• Collaborative and able to work effectively across disciplines and organisations to deliver joined-up care
• Person centred (Prioritises the individuals needs, preferences, and dignity)
• Innovative: Seeks out and applies evidence-based practices and new models of care
• Takes responsibility for clinical decisions and service outcomes
• Engages in continuous professional development and reflective practice
• Promotes equality, diversity, and cultural competence in care delivery
• Able to use own initiative but also know when to seek assistance
• Ability to work under pressure

Skills

Essential

• Excellent communication skills (written and oral)
• Strong IT skills
• Advanced clinical assessment and diagnostic skills, particularly in geriatric and frailty syndromes
• Knowledge of national standards that inform practices e.g. NICE guidelines
• Expertise in frailty identification and screening tools (e.g. Clinical Frailty Scale, eFI).
• Knowledge of clinical and information governance as appropriate to role
• Sound understanding of long-term condition management, rehabilitation and end-of-life care
• Proven ability to work effectively within MDTs and across organisational boundaries
• Understanding of personalised care, wider determinants of health and equality, diversity and inclusion
• Ability to engage with and enable people, families and carers using health coaching approaches
• Ability to enable efficient multi-agency working with practitioners across the system adopting a team of teams approach, especially with the local Integrated Neighbourhood Team
• Competence in using digital health records and remote monitoring tools
• Willing to become competent in use of SystmOne if not already
• Competent in the use of Office and Outlook
• Ability to follow policy and procedure
• Able to identify and resolve risk management issues according to policy or protocol
• Ability to assess, implement and evaluate a programme of care
• Effective time management (planning and organising)
• Ability to work as a team member and autonomously
• Good interpersonal skills
• An ability to drive, current UK driving licence and daily access to a vehicle

Desirable

• Competent in use of SystmOne
• Understanding of the wider determinants of health, including social, economic and environmental factors and their impact on communities

Qualifications

Essential

• Registered Adult Nurse/Registered General Nurse or other qualification recognised by the NMC as equivalent
• Current registration with Nursing & Midwifery Council

Desirable

• Post-graduate training in a relevant subject

Disclosure and Barring Service Check

This post is subject to the Rehabilitation of Offenders Act (Exceptions Order) 1975 and as such it will be necessary for a submission for Disclosure to be made to the Disclosure and Barring Service (formerly known as CRB) to check for any previous criminal convictions.

UK Registration

Applicants must have current UK professional registration. For further information please see NHS Careers website (opens in a new window).