Job summary
Various hours available
Fancy
a new challenge? Are you someone who is dynamic & a positive team member
that is passionate about patient care?
We're
looking for a Frailty Nurse to join our innovative Neighbourhood Nursing Teams
across Barnsley
We have an
exciting opportunity for an enthusiastic, motivated Registered Nurse, working closely
with & under the direction of the Community Matrons providing appropriate
services to people who are moderately/severely frail & have long term
conditions
This
role is integral to the assessment of patient frailty levels & assisting
with review of patients to allow the best access to care required for their
support
You
will be an autonomous practitioner who holds a delegated responsibility for a
defined caseload
Were
looking for someone 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 driving license & access
to a vehicle on a daily basis
All employees of
the Trust are strongly encouraged to be fully vaccinated against COVID-19 to
protect patients.
Main duties of the job
As
a Frailty Nurse you will:
Work
in partnership with other health professionals, supporting housebound &
care home residents to provide holistic patient care.
Support
the virtual ward pathway, providing care to patients accessing the Virtual Ward
frailty pathway
Assess,
plan, implement and evaluate care.
Demonstrate
extensive knowledge, advanced analytical & practical skills.
Participate
in MDT meetings to discuss & feedback regarding patients that the Frailty
Nurse has supported.
Have high level communication/interpersonal
skills to negotiate & establish collaborative partnerships with
patients & care professionals.
Have
enthusiasm & the ability to use your own initiative are essential.
Participate in education & staff development, actively participate in regular
supervision & appraisals.
Think
you could rise to the challenge?
Up
to full and part time hours are available
About us
We
are a specialist NHS Foundation Trust that provides community, mental health
and learning disability services for the people of Barnsley, Calderdale,
Kirklees and Wakefield. We also provide low and medium secure services and are
the lead for the west Yorkshire secure provider collaborative.
Our mission is
to help people reach their potential and live well in their communities, we do this
by providing high-quality care in the right place at the right time. We employ
staff in both clinical and non-clinical services who work hard to make a
difference to the lives of service users, families and carers.
We encourage
and welcome applications from all protected characteristic groups, we value
diversity and want our workforce to be reflective of our communities.
Being
a foundation Trust means were accountable to our
members, who can have a say in how were run. Around 14,300 local people
(including staff) are members of our Trust.
Join
us and you will be one of over 4,500 staff committed to supporting and improving
the mental, physical and social needs of the thousands of people we meet and
help each year.
We
are committed
to safeguarding and promoting the welfare of children, young people and
vulnerable adults and expects all colleagues and volunteers to share this
commitment.
We do reserve to right to close vacancy before the advertised closing date if necessary, so please apply as soon as possible.
Job description
Job responsibilities
JOB SUMMARY
This job description is an outline of the main duties of the post. The postholder will be required to undertake other duties commensurate with the grade as directed.
The content of this post will be reviewed in consultation with the postholder when necessary and in line with the service developments.
JOB PURPOSE
1. To work within the Integrated Neighbourhood Teams under the direction of the Community Matrons providing appropriate services to people who are moderately / severely frail and have long term conditions.
2. To assess the health needs of designated clients and plan, implement and evaluate programmes of care in response to identified need.
3. To contribute to the public health role within the team.
KEY RESULT AREAS:
CORE DUTIES AND RESPONSIBILITIES:
- To visit clients who meet the Frailty Nursing criteria within their usual place of residence (care homes and/or the clients own home) and undertake designated duties.
- To assess for and identify the health needs of patients who are frail and who may have a long-term condition using single assessment process.
- 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 Personal Health and Social Care Plans.
- Develop disease specific patient information and education to support patients self care..
- To contribute to/lead on the delivery and development of public health activities in response to identified needs and local ICS or national targets. Topics include nutrition, physical activity, falls prevention, mental health promotion, stop smoking and affordable warmth.
- To work in partnership with other health professionals, statutory and voluntary services in order to improve health outcomes for clients and address inequalities in health.
- Link people to voluntary and peer groups for support with self management e.g. Diabetes UK, Age UK where appropriate.
- To provide support for Carers, including facilitating independent assessment of carers needs as appropriate.
- Record all client contacts and activities accurately and contemporaneously, maintaining accurate records in line with trust standards, via SystmOne.
- Be responsible for updating knowledge and skills and maintaining professional competency and development, including accessing clinical supervision.
- Work within the clinical governance framework to maintain consistent high standards of care, working from an evidence base or current best practice.
- Participate in the training and education of other health care professionals and students providing an appropriate learning environment.
- Have an awareness of and adhere to trust policies and procedures in relation to matters of child and adult safeguarding.
- Adhere to the NMC Code of Conduct and Trust Policies and Procedures.
Supporting Housebound Patients
- Undertake an in-depth holistic frailty assessment for all patients identified as having moderate and high-risk levels of frailty, as identified by Integrated Neighbourhood Team clinical colleagues.
- Implement appropriate plans of care to address the patients existing level of frailty and minimise further deterioration. This may include onward referral to appropriate services / agencies and regular review as necessary.
- Undertake advanced care planning (including the completion of EPaCCS) with frailty and / or long-term condition patients who are deemed to have capacity, as appropriate.
- Participate when required in best interest decision making at MDTs.
- Undertake a comprehensive falls assessment on patients identified as requiring this assessment following an initial falls screening tool being undertaken by the Community Matron.
- Undertake long term condition reviews (Chronic Disease / COPD / Asthma) for housebound patients as requested by primary care colleagues.
Supporting Care Home Residents
- Following notification from the RightCare Integrated SPA of a care home residents discharge from hospital, the Frailty Nurse will liaise via telephone with the care home to ascertain whether a face to face intervention is required.
- Support the Community Matron by attending and contributing to the Enhanced Care in Care Homes care home MDTs / weekly ward rounds.
- Continue to undertake annual LTC review requests (Chronic Disease / COPD / Asthma) for care home residents received from GP Practices.
Virtual Ward Related Duties
- To support the virtual ward pathway through playing an active role in providing care to patients accessing the Virtual Ward frailty pathway. This will include being dispatched to virtual ward frailty patients in the event of a virtual ward nurse requesting a visit following their virtual monitoring identifying that the patient is requires a face to face intervention.
- Support the Community Matrons by visiting virtual ward patients as requested by the Matron to undertake observations and appropriate clinical assessments.
- To respond to patients who may have alerted via the virtual ward digital monitoring equipment following notification of the alert from the RightCare Barnsley virtual ward nursing team.
- Participate within the Virtual Ward Multi-Disciplinary Team Meetings to discuss and feedback regarding patients that the Frailty Nurse has supported.
COMMUNICATION WITH OTHERS:
Clients, carers and their families.
Members of the Primary Health Care Team.
Other health professionals and statutory and voluntary agencies as appropriate
For full details of the role please see the supporting documents attached.
Job description
Job responsibilities
JOB SUMMARY
This job description is an outline of the main duties of the post. The postholder will be required to undertake other duties commensurate with the grade as directed.
The content of this post will be reviewed in consultation with the postholder when necessary and in line with the service developments.
JOB PURPOSE
1. To work within the Integrated Neighbourhood Teams under the direction of the Community Matrons providing appropriate services to people who are moderately / severely frail and have long term conditions.
2. To assess the health needs of designated clients and plan, implement and evaluate programmes of care in response to identified need.
3. To contribute to the public health role within the team.
KEY RESULT AREAS:
CORE DUTIES AND RESPONSIBILITIES:
- To visit clients who meet the Frailty Nursing criteria within their usual place of residence (care homes and/or the clients own home) and undertake designated duties.
- To assess for and identify the health needs of patients who are frail and who may have a long-term condition using single assessment process.
- 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 Personal Health and Social Care Plans.
- Develop disease specific patient information and education to support patients self care..
- To contribute to/lead on the delivery and development of public health activities in response to identified needs and local ICS or national targets. Topics include nutrition, physical activity, falls prevention, mental health promotion, stop smoking and affordable warmth.
- To work in partnership with other health professionals, statutory and voluntary services in order to improve health outcomes for clients and address inequalities in health.
- Link people to voluntary and peer groups for support with self management e.g. Diabetes UK, Age UK where appropriate.
- To provide support for Carers, including facilitating independent assessment of carers needs as appropriate.
- Record all client contacts and activities accurately and contemporaneously, maintaining accurate records in line with trust standards, via SystmOne.
- Be responsible for updating knowledge and skills and maintaining professional competency and development, including accessing clinical supervision.
- Work within the clinical governance framework to maintain consistent high standards of care, working from an evidence base or current best practice.
- Participate in the training and education of other health care professionals and students providing an appropriate learning environment.
- Have an awareness of and adhere to trust policies and procedures in relation to matters of child and adult safeguarding.
- Adhere to the NMC Code of Conduct and Trust Policies and Procedures.
Supporting Housebound Patients
- Undertake an in-depth holistic frailty assessment for all patients identified as having moderate and high-risk levels of frailty, as identified by Integrated Neighbourhood Team clinical colleagues.
- Implement appropriate plans of care to address the patients existing level of frailty and minimise further deterioration. This may include onward referral to appropriate services / agencies and regular review as necessary.
- Undertake advanced care planning (including the completion of EPaCCS) with frailty and / or long-term condition patients who are deemed to have capacity, as appropriate.
- Participate when required in best interest decision making at MDTs.
- Undertake a comprehensive falls assessment on patients identified as requiring this assessment following an initial falls screening tool being undertaken by the Community Matron.
- Undertake long term condition reviews (Chronic Disease / COPD / Asthma) for housebound patients as requested by primary care colleagues.
Supporting Care Home Residents
- Following notification from the RightCare Integrated SPA of a care home residents discharge from hospital, the Frailty Nurse will liaise via telephone with the care home to ascertain whether a face to face intervention is required.
- Support the Community Matron by attending and contributing to the Enhanced Care in Care Homes care home MDTs / weekly ward rounds.
- Continue to undertake annual LTC review requests (Chronic Disease / COPD / Asthma) for care home residents received from GP Practices.
Virtual Ward Related Duties
- To support the virtual ward pathway through playing an active role in providing care to patients accessing the Virtual Ward frailty pathway. This will include being dispatched to virtual ward frailty patients in the event of a virtual ward nurse requesting a visit following their virtual monitoring identifying that the patient is requires a face to face intervention.
- Support the Community Matrons by visiting virtual ward patients as requested by the Matron to undertake observations and appropriate clinical assessments.
- To respond to patients who may have alerted via the virtual ward digital monitoring equipment following notification of the alert from the RightCare Barnsley virtual ward nursing team.
- Participate within the Virtual Ward Multi-Disciplinary Team Meetings to discuss and feedback regarding patients that the Frailty Nurse has supported.
COMMUNICATION WITH OTHERS:
Clients, carers and their families.
Members of the Primary Health Care Team.
Other health professionals and statutory and voluntary agencies as appropriate
For full details of the role please see the supporting documents attached.
Person Specification
Experience
Essential
- Demonstrable nursing experience across a variety of settings.
- Experience of delivering patient education and promoting self directed care.
- Experience of working with clients with long term conditions.
- Experience of working independently.
- Experience of identifying, assessing and implementing care for frail patients.
Desirable
- Community nursing experience.
- Experience of health behaviour change and/or health and wellbeing programmes.
- Experience in coaching and behavioural change techniques.
- Experience of using the Rockwood Frailty Score.
SPECIAL KNOWLEDGE/SKILLS
Essential
- Excellent communication (both written and verbal) and negotiation skills.
- Ability to use own initiative.
- Excellent organisational skills.
- Understanding and commitment to promoting the principles of self directed care including understanding of health, social care and voluntary care support systems.
- Knowledge and understanding of current government legislation and NHS policy.
- Evidence of health promotion skills.
Desirable
- Understanding of how Telehealth and other long term conditions self management initiatives can maximise the patients quality of life.
- Ability to use web-based learning materials.
- IT literate - including Word and Excel.
Qualifications
Essential
- RGN.
- Nursing degree / diploma.
- Evidence of meeting PREP Requirements.
- Experience of mentoring/supporting learners or ability to demonstrate the skills required for effective mentoring.
Desirable
- Evidence of skills in:
- Venepuncture
- Male catheterisation
- Syringe driver use
- Ear syringing
TRAINING
Essential
- An understanding under the umbrella of LTC Disease areas.
- Trained in motivational interviewing and behavioural change techniques or willing to undertake.
- Completion of Health Education Englands e-Learning for Healthcare (elfh) Tier 2a Frailty qualification or willing to undertake within 6 months of being in post.
PERSONAL ATTRIBUTES
Essential
- Ability to engage and communicate with patient, carers, health professionals both face to face and over the telephone.
- Ability to work as part of a team.
- Motivated and enthusiastic to support patients and their carers to maximise their health and wellbeing.
- A current driving licence and access to a car during the working day is essential (reasonable adjustments will be considered for any applicants who are unable to drive due to a disability)
- Professional approach.
- Ability to work flexibly including weekend, evening and Bank Holiday working.
PHYSICAL ATTRIBUTES
Essential
- Ability to undertake the duties and demands of the post. A satisfactory sickness record over the previous 2 years (subject to the need to act with fairness and equality of opportunity, particularly where the sickness is related to a disability and/or pregnancy).
Person Specification
Experience
Essential
- Demonstrable nursing experience across a variety of settings.
- Experience of delivering patient education and promoting self directed care.
- Experience of working with clients with long term conditions.
- Experience of working independently.
- Experience of identifying, assessing and implementing care for frail patients.
Desirable
- Community nursing experience.
- Experience of health behaviour change and/or health and wellbeing programmes.
- Experience in coaching and behavioural change techniques.
- Experience of using the Rockwood Frailty Score.
SPECIAL KNOWLEDGE/SKILLS
Essential
- Excellent communication (both written and verbal) and negotiation skills.
- Ability to use own initiative.
- Excellent organisational skills.
- Understanding and commitment to promoting the principles of self directed care including understanding of health, social care and voluntary care support systems.
- Knowledge and understanding of current government legislation and NHS policy.
- Evidence of health promotion skills.
Desirable
- Understanding of how Telehealth and other long term conditions self management initiatives can maximise the patients quality of life.
- Ability to use web-based learning materials.
- IT literate - including Word and Excel.
Qualifications
Essential
- RGN.
- Nursing degree / diploma.
- Evidence of meeting PREP Requirements.
- Experience of mentoring/supporting learners or ability to demonstrate the skills required for effective mentoring.
Desirable
- Evidence of skills in:
- Venepuncture
- Male catheterisation
- Syringe driver use
- Ear syringing
TRAINING
Essential
- An understanding under the umbrella of LTC Disease areas.
- Trained in motivational interviewing and behavioural change techniques or willing to undertake.
- Completion of Health Education Englands e-Learning for Healthcare (elfh) Tier 2a Frailty qualification or willing to undertake within 6 months of being in post.
PERSONAL ATTRIBUTES
Essential
- Ability to engage and communicate with patient, carers, health professionals both face to face and over the telephone.
- Ability to work as part of a team.
- Motivated and enthusiastic to support patients and their carers to maximise their health and wellbeing.
- A current driving licence and access to a car during the working day is essential (reasonable adjustments will be considered for any applicants who are unable to drive due to a disability)
- Professional approach.
- Ability to work flexibly including weekend, evening and Bank Holiday working.
PHYSICAL ATTRIBUTES
Essential
- Ability to undertake the duties and demands of the post. A satisfactory sickness record over the previous 2 years (subject to the need to act with fairness and equality of opportunity, particularly where the sickness is related to a disability and/or pregnancy).
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).
Additional information
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).
