Job responsibilities
Job
title
Frailty
Nurse
Line
Manager
Frailty
Matron
Accountable
to
PCN
Board Directors / PCN Clinical Lead
Location
or work
Bowery
Hub / Field Based
Hours
per week
Full-time
/ Part-time considered (37.5 hours FTE)
Organisational
Overview
Primary Care Networks (PCNs) are a key part of the NHS Long Term
Plan, with General Practices grouping together to form a network of
Practices, supported by a number of additional clinical roles.
The St Helens South Primary Care Network Limited Company (PCN)
is the organisation that delivers the core components of the PCN Contract as
well as supports the wider Primary Care system and tenders for, designs and
develops new/ existing services for the benefit of the St Helens South
population.
The PCN is comprised of 10 Practices in the St Helens South
areas. The practices have a combined geographic area made up of around 85,000
patients.
This role will contribute to the improving quality of care of
our patients across the PCN and its network of practices.
Job
Summary
The post holder will play a vital role in delivering
high-quality, person-centred care to adults living with frailty within the
Primary Care Network (PCN). Working as an autonomous practitioner and
integral member of the multidisciplinary team, the Frailty Nurse will assess,
plan, deliver and evaluate holistic care for patients identified as living
with moderate to severe frailty.
The role involves advanced clinical assessment, care planning,
medication review support, health promotion, and the coordination of
proactive and reactive care to prevent avoidable hospital admissions and
promote independence.
PCN
Values and Employee Statement
Behave
consistently with the values and beliefs of the PCN and promote these on a
day-to-day basis. By actively living out the PCN CARE Values in everyday work,
helping to create a positive and supportive culture while contributing to a
high-quality experience for both colleagues and patients.
Primary
responsibilities
Clinical
Practice:
- Contribute to the delivery of care
provision to our frail and elderly populations including proactive
Person-Centred Care Planning and collaborative working to deliver the
Enhanced Health in Care Homes DES as a senior member of the Frailty team.
- Early identification and recognition
of deterioration to include proactive care and escalation planning.
- Full comprehensive geriatric
assessment for residents that have moderate to severe frailty to support the
coordination of care with community and urgent
care services.
- Recognising common medications relating to frailty.
within caseload for acute and chronic conditions.
- Understand the degree of frailty,
mild moderate or severe and the 5 frailty syndromes enabling the correct
proportionate response to a patient need
- To support proactive, anticipatory
and advance care planning using an agreed set of validated, evidence-based
assessment tools to help identify the degree of need, e.g. Respect and EPaCCS
- Ordering, performing and interpreting
relevant clinical test and investigations
- Providing expert frailty advice and
guidance and education where necessary to medical, nursing, clinical care
coordinators and other MDT colleagues.
- Assess and manage acute, chronic and
acute on chronic conditions in relation to frailty to uphold patient safety
and prevent admission where possible.
-
Provide weekly care home support and management in conjunction with
homes and community service
-
Support necessary vaccination campaigns within care homes
-
Provide high quality mental health and dementia care, offering support
and guidance to homes, working in collaboration with community services
-
Undertake high standards of clinical record keeping including
electronic data entry and recording of patient record
-
Deliver nursing interventions such as wound care, catheter care, and
falls risk assessments.
Coordination
and Partnership Working:
-
Liaise with GPs, social workers, occupational / therapists, care
coordinators, social prescribers and voluntary sector partners.
-
Working with other practitioners and agencies within the Primary Care
Network and local system as necessary to develop patient specific treatment
plans and ensure Care Pathways are utilised.
-
Lead or contribute to MDT meetings, virtual wards, and care home ward
rounds.
-
Develop relationships with care homes and domiciliary care providers
to support consistent care.
-
Act as a key point of contact for patients, carers, and families to
promote continuity of care.
Education,
Support & Development:
-
Support training and development of junior nurses, Clinical Care Coordinators
and student nurses (where applicable)
-
Educate patients and carers in self-management and preventative
strategies.
-
Identify and support educational opportunities to work with care
homes, for example completion of Respect Documents, hydration and nutritional
support and good oral health care
- Monitor and lead improvements to
standards of care through, supervision of practice, clinical audit,
evidence-based practice, teaching and supporting professional colleagues and
the provision of skilled professional leadership.
-
Participate in audits, QI projects and service development
initiatives.
Leadership
and Governance:
-
Adhere to NMC Code of Conduct and professional standards at all times.
-
Maintain accurate clinical documentation and use clinical systems
(e.g., EMIS/GP Connect).
-
Contribute to safeguarding reviews, risk assessments and incident
reporting.
-
Work within agreed local policies, PCN protocols and national
frameworks (e.g., NHS Long Term Plan, EHCH DES).
Person
Specification Care coordinator
Qualifications
- Registered
Nurse (Adult) (Essential)
- MSc in Advanced Clinical Practice or
equivalent (Desirable)
- Professional
registration with NMC (Essential)
- Independent
prescribing (V300) (Desirable)
- Clinical
exam and diagnostics (or equivalent) Level 7 (Essential)
- Post registration education/experience in
frailty, care of the elderly, palliative care, dementia, long term conditions (Essential)
- Minimum
5 years post-registration experience (Essential)