Job summary
Do you want to contribute to reducing avoidable hospital admissions and improve patients experiences? Would you like to influence the ongoing development of frailty and palliative care integration in the local community? Then we'd be keen to hear from you!
Following the success of a 12-month funded pilot scheme, St Leonard's Hospice is delighted to offer a permanent Palliative Care Frailty Nurse Coordinator role, working collaboratively between the Nimbuscare Frailty Hub and the Hospice to help shift access to palliative care toward non-cancer diagnoses, addressing long-standing inequity in end of life provision for people living with frailty and dementia.
Originally supported through funding secured via Hospice UK, this role has now demonstrated significant clinical impact, improved patient outcomes, and strong system value and is being sustained directly by the Hospice in recognition of its success.
This is a full-time position working 37.5 hours per week 5 days over 7 during normal office hours. Whilst you will be employed by St Leonard's Hospice, this role will be based within The Frailty Hub at Acomb Garth, York however you will be expected to spend regular time at the main Hospice site on Tadcaster Road, York.
Main duties of the job
Working autonomously as the Palliative Care Frailty Nurse Coordinator your main priorities will be to provide:
- Reactive crisis support for frail patients deteriorating in the community
- Proactive anticipatory care planning for patients identified as high risk of decline
- Completed ReSPECTs, prescribe anticipatory medication and co-ordinate community services
- A relationship-focussed service that sits at the interface between primary care, frailty and specialist palliative care services
Our ideal candidates will be:
- A Registered Nurse who has experience in either palliative care/ community nursing/ frailty services and understands system navigation and coordination of complex care
- Skilled in advance care planning and be able to handle sensitive conversations
- Confident working autonomously within multidisciplinary environments
What we can offer you in return:
- Salary above NHS pay scales
- Reimbursement of NMC fees
- Up to 41 days Annual Leave
- Continuation of NHS pension and annual leave entitlement (T&Cs apply)
- Attractive pension scheme for non-NHS staff
- Free car parking
- A supportive and friendly working environment
This role will be a rewarding role which will integrate palliative care expertise into the community frailty service to support approximately 3,500 high-risk patients in York and the surrounding area. Apply now!
About us
Our mission is to provide excellent care and support to those living with life-limiting illness and to the people they care about, to enrich their lives and to contribute to the ongoing development of end-of-life care. We do this by placing our patients at the centre of everything we do, and through involving patients and their families in all decisions regarding their care.
We can only achieve this with the help of our amazing colleagues, by developing and recognising their contribution, and by sharing our knowledge and skills through education, audit and research.
We do not have sponsorship status and therefore all our offers are made conditional upon our candidates submitting evidence of their right to work in the UK in conjunction with our other pre-employment checks.
Job description
Job responsibilities
The Palliative Care Frailty Nurse Coordinator will work at the interface between frailty, primary care and specialist palliative services to:
Achieve early identification of frail patients approaching the end of life
- Reduce crisis-driven hospital admissions
- Enable anticipatory care planning
- Support patients to die in their preferred place
The role combines proactive identification and planning with responsive crisis coordination, focusing particularly on addressing the inequity of access for people with advanced frailty and dementia.
Key Responsibilities
Clinical Practice
1. Assess frail patients who may be approaching the end of life and make clear plans to meet their needs.
2. Lead and support advance care planning conversations including ReSPECT documentation.
3. Prescribe in line with the scope of professional practice.
4. Coordinate community services by liaising with system partners to prevent avoidable hospital admissions.
5. Provide responsive input for patients deteriorating in the community by the provision of specialist nursing support.
6. Support the delivery of multi-disciplinary care to enable home deaths where this is aligned with patient preferences.
7. Maintain accurate, legible documentation and communicate necessary information to all relevant team members.
System Collaboration and Leadership
1. Identify high-risk patients using frailty scores, clinical intelligence, and MDT discussion to proactively provide support.
2. Work closely with an extended multi-disciplinary team (MDT) to embed anticipatory approaches to palliative provision for frail patients.
3. Support earlier ceilings-of-care discussions in patients with recurrent admissions, enabling home focus where this is the patients preference.
4. Act as the palliative care link within the Frailty Hub MDT and develop strong working relationships with community service providers alongside specialist palliative care teams.
Education and Governance
1. Provide education, training and support to the wider workforce.
2. Promote the embedding of advance care planning discussions within mainstream clinical practice across the Hospices network.
3. Contribute to audit and evaluation of service outcomes.
4. Participate in clinical governance structures within the Hospice.
Job description
Job responsibilities
The Palliative Care Frailty Nurse Coordinator will work at the interface between frailty, primary care and specialist palliative services to:
Achieve early identification of frail patients approaching the end of life
- Reduce crisis-driven hospital admissions
- Enable anticipatory care planning
- Support patients to die in their preferred place
The role combines proactive identification and planning with responsive crisis coordination, focusing particularly on addressing the inequity of access for people with advanced frailty and dementia.
Key Responsibilities
Clinical Practice
1. Assess frail patients who may be approaching the end of life and make clear plans to meet their needs.
2. Lead and support advance care planning conversations including ReSPECT documentation.
3. Prescribe in line with the scope of professional practice.
4. Coordinate community services by liaising with system partners to prevent avoidable hospital admissions.
5. Provide responsive input for patients deteriorating in the community by the provision of specialist nursing support.
6. Support the delivery of multi-disciplinary care to enable home deaths where this is aligned with patient preferences.
7. Maintain accurate, legible documentation and communicate necessary information to all relevant team members.
System Collaboration and Leadership
1. Identify high-risk patients using frailty scores, clinical intelligence, and MDT discussion to proactively provide support.
2. Work closely with an extended multi-disciplinary team (MDT) to embed anticipatory approaches to palliative provision for frail patients.
3. Support earlier ceilings-of-care discussions in patients with recurrent admissions, enabling home focus where this is the patients preference.
4. Act as the palliative care link within the Frailty Hub MDT and develop strong working relationships with community service providers alongside specialist palliative care teams.
Education and Governance
1. Provide education, training and support to the wider workforce.
2. Promote the embedding of advance care planning discussions within mainstream clinical practice across the Hospices network.
3. Contribute to audit and evaluation of service outcomes.
4. Participate in clinical governance structures within the Hospice.
Person Specification
IT
Essential
- Good basic IT skills
- Knowledge of Microsoft applications (Word, Excel, PowerPoint, Outlook)
Desirable
- Knowledge and experience of CPD and SystmOne
Other requirements
Essential
- Full UK driving licence and access to vehicle
- Willingness to work flexibly according to service need
- Be prepared to assist with Hospice fundraising activities
- Enhanced DBS
Experience
Essential
- Experience in palliative care, community nursing, or frailty services
- Confident in advance care planning and sensitive conversations
- Experience working across organisational boundaries
- Ability to work autonomously and prioritise complex caseloads
Desirable
- Experience of service development or quality improvement
- Experience contributing to audit or evaluation
Communication
Essential
- Excellent written and verbal communication
- Ability to communicate sensitively with patients, carers and staff about their health needs
- Collaborative and relationship-focused approach to work
Personal
Essential
- Compassionate and patient-centred
- Resilient and adaptable
- Comfortable with managing clinical uncertainty in frailty trajectories
- Motivated
Qualifications
Essential
- Registered Nurse
- Non-Medical Prescriber (NMP)
Desirable
- Community/District Nursing qualification
- Mentorship/Teaching and Assessing qualification
- European Certificate in Palliative Care qualification (or similar)
- Advanced Communication skills training
Person Specification
IT
Essential
- Good basic IT skills
- Knowledge of Microsoft applications (Word, Excel, PowerPoint, Outlook)
Desirable
- Knowledge and experience of CPD and SystmOne
Other requirements
Essential
- Full UK driving licence and access to vehicle
- Willingness to work flexibly according to service need
- Be prepared to assist with Hospice fundraising activities
- Enhanced DBS
Experience
Essential
- Experience in palliative care, community nursing, or frailty services
- Confident in advance care planning and sensitive conversations
- Experience working across organisational boundaries
- Ability to work autonomously and prioritise complex caseloads
Desirable
- Experience of service development or quality improvement
- Experience contributing to audit or evaluation
Communication
Essential
- Excellent written and verbal communication
- Ability to communicate sensitively with patients, carers and staff about their health needs
- Collaborative and relationship-focused approach to work
Personal
Essential
- Compassionate and patient-centred
- Resilient and adaptable
- Comfortable with managing clinical uncertainty in frailty trajectories
- Motivated
Qualifications
Essential
- Registered Nurse
- Non-Medical Prescriber (NMP)
Desirable
- Community/District Nursing qualification
- Mentorship/Teaching and Assessing qualification
- European Certificate in Palliative Care qualification (or similar)
- Advanced Communication skills training
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.
