Frailty Nurse

Job responsibilities

JOB SUMMARY

Meridian Medical Primary Care Network (PCN) is made up of the four practices consisting of East Lindsey Medical Group, James Street Family Practice based in Louth: Tasburgh Lodge Surgery in Woodhall Spa and Marsh Medical Practice in North Somercotes. The PCN serves a population of approximately 42,670 patients and the four practices work together to provide targeted quality health services across the geographical area covered by these practices.

As part of the Network Contract DES, Meridian Medical PCN is required to deliver the Enhanced Health in Care Home framework (EHCH) to the care homes to which it is aligned, and to nominate a clinical lead to oversee the service. The PCN Frailty Nurse will improve the quality and safety of care offered to patients of care homes of Meridian Medical PCN. They will have regular contact with the patients and care home staff and will reduce the workload for GPs with the Meridian Medical PCN, as well as supporting the management of patients with long-term conditions.

We are looking to recruit a band 6 Frailty Nurse to co-ordinate proactive quality care for the nursing homes within the network as part of the EHCH.

This role will require an experienced clinician who has practiced within the care home or frailty environment. The candidate must be confident in multi-disciplinary working, to participate in MDT and planning meetings and should link with the other members of our Primary Care Community Team, working with various stakeholders such as GPs, Paramedics, Neighbourhood Team Lead and community staff, Care Co-Ordinators, Mental Health Practitioners, Clinical Pharmacists, Occupational Therapist and Social Prescribing Link Workers to support the co-ordination and delivery of integrated patient care and influence service development.

Key aims of the role are:

Increase safety, quality and continuity of care for care home patients

To complete comprehensive individualised frailty assessments

To complete individualised respect forms

To adhere to relevant Health & Social Care, local and national policy and procedures

JOB ROLES AND RESPONSIBILITIES

Meridian Medical PCN has a number of care homes (residential and nursing) with capacity to provide care for approximately 461 residents. These range in size from smaller units with less than 10 beds to homes with over 30 beds and include some supporting those living with dementia, learning difficulties (LR) and/or complex physical health needs. The post holder will work as part of our local multi-disciplinary team to ensure that all patients in the care setting are treated with dignity and respect. You will build relationships with all care home staff and during working hours act as a point of contact for residents, families and professionals.

The successful candidate will work as part of a multidisciplinary team to manage patients on transfer of care and systems to mitigate hospital admissions. The post holder will complete face to face frailty assessments.

Duties of the role:

To undertake home visits in accordance with the relevant protocols

To make professionally autonomous decisions for which he/she is accountable

Prioritise health problems and intervene appropriately to assist with the patient in complex, urgent or emergency situations, including initiation of effective emergency care

Support patients and their families/care home staff to adopt health promotion strategies that promote healthy lifestyles, and apply principles of self-care

Assess, identify and refer patients presenting with mental health needs in accordance with the NSF for Mental Health

To ensure that professional standards are maintained and within the guidance provided by the Royal College of Nursing (RCN)

To support the development of excellent relationships across the PCN to enable collaboration for better patient outcomes

To contribute to the PCN achieving its quality targets to sustain high standards of patient care and service delivery

To support in the delivery of enhanced services and other service requirements on behalf of the PCN

To undertake all mandatory training and induction programmes

To provide effective, visible leadership that encourages a culture of professionalism, compassion, excellence and the development of effective team working

To be accountable for ones own self-development and maintain update knowledge base on national and local policy

Key working relationships

Local care homes

PCN EHCH Multi-Disciplinary Team

Local Neighbourhood Team

GP Practices within the PCN

Practice Leaders (Partners and Practice Managers)

PCN Social Prescribers

PCN Clinical Pharmacists

PCN Clinical Directors and LADMS General Manager

PCN Care Co-Ordinator

Clinical Commissioning Group (CCG) and NHSE

Community Health Teams both physical and mental health

Local Authority

CONFIDENTIALITY

In the course of seeking treatment, patients entrust us with or allow us to gather sensitive information in relation to their health and other matters. They do so in confidence and have the right to expect that staff will respect their privacy and act appropriately.

In the performance of the duties outlined in this job description, the post-holder may have access to confidential information relating to patients and their carers, practice staff and other healthcare workers. They may also have access to information relating to the PCN as a business organisation. All such information from any source is to be regarded as strictly confidential.

Information relating to patients, carers, colleagues, other healthcare workers or the business of the PCN may only be divulged to authorised persons in accordance with the employing practice policies and procedures relating to confidentiality and the protection of personal and sensitive data.

EQUALITY AND DIVERSITY

The post-holder will support the equality, diversity and rights of patients, careers 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 and the member practices procedures and policies, and current legislation

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

Behaving in a manner which is welcoming to and of the individual, is non-judgemental and respects their circumstances, feelings, priorities and rights

PERSONAL AND PROFESSIONAL DEVELOPMENT

The post-holder will participate in any training programme implemented by the PCN as part of this employment, with such training to include:

Adherence to the Royal College of Nursing Code of Professional conduct, scope of professional practice and maintain registration

To be aware of and work within the policies of Meridian Medical PCN

Participation in an annual individual performance review, including taking responsibility for maintaining a record of their own personal and/or professional development

Participation in the PCN mandatory training programme

To develop and sustain own personal and professional development, clinical skills and professional awareness in accordance with PREP requirements and the on-going demands of the role

To contribute to the development and review of related clinical policies, protocols and guidelines

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

RISK MANAGEMENT:

You have a responsibility for the identification of all risks which could have a potential adverse effect on the organisations ability to maintain quality of care and the safety of patients, staff and visitors and for taking positive action to eliminate or reduce these.

HEALTH AND SAFETY:

To maintain a god working knowledge of health and safety procedures and fire precautions; to operate the correct procedures and participate in policy development and data collection where appropriate

The post holder has a duty of care and personal obligation to act to reduce healthcare-associates infections (HCAIs). They must attend mandatory training in infection prevention and control (IP&C) and be compliant with all measures required by the PCN to reduce these. They must also be familiar with all infection prevention and control policies used within the PCN, including those that apply to their duties, such as hand decontamination, personal protective equipment, aseptic techniques and safe disposal of Sharps.

QUALITY

The post-holder will strive to maintain quality within the PCN and will:

Alert other team members to issues of quality and risk

Assess own performance and take accountability for their 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 with individuals in other agencies to meet patients needs

Effectively manage own time, workload and resources

COMMUNICATION

The post-holder should recognise the importance of effective communication within the team and will strive to:

Demonstrate sensitive communication styles to ensure patients are fully informed and consent to treatment

Communicate effectively with patients and carers recognising the need for alternative methods of communication to overcome different levels of understanding, cultural background and preferred ways of communicating

Anticipate barriers to communication and take action to improve communication

Maintain good communications with the GPs and the wider multi-disciplinary team, to sustain a high standard of service and safety to the patient

Recognise peoples needs for alternative methods of communication and respond accordingly

The post holder will promote good communication within the PCN and MDT by being approachable and knowledgeable regarding all aspects of patient services

Persona Attributes

Essential

• Ability to work independently as well as collaboratively in a team
• Ability to follow legal, ethical, professional and organisational
• policies/procedures and codes of conduct
• Ability to use own initiative, discretion and sensitivity
• Able to get along with people from all backgrounds and communities, respecting lifestyles and diversity
• Flexible and co-operative
• Ability to identify risk and assess/manage risk when working with individuals
• Sensitive and empathetic in distressing situations
• Able to provide leadership and to finish work tasks
• Transparency and honesty
• High professional standards
• Problem solving and analytical skills
• Ability to maintain confidentiality
• Knowledge of and ability to work to policies and procedures, including confidentiality, safeguarding, lone working, information governance and health and safety
• Committed to person-centred, non-discriminatory practice
• Professional, approachable and respectful attitude towards others
• Able to maintain judgement under pressure
• Able to maintain motivation, drive and enthusiasm
• Confident approach
• Flexible approach to work
• Ability to travel around the PCN patch to deliver patient care
• An ability to provide constructive feedback in a professional manner
• Recognises the roles of other colleagues and their role in delivering patient care
• Ability to recognise personal limitations and refer to more appropriate colleagues when necessary

Desirable

• An ability to provide constructive feedback in a professional manner
• Recognises the roles of other colleagues and their role in delivering patient care
• Ability to recognise personal limitations and refer to more appropriate colleagues when necessary

Experience

Essential

• Demonstrate post-registration qualification experience
• Demonstrable experience of working in the community
• Demonstrable experience of co-working in complex and challenging environments
• Experience of managing risks and reporting and escalating concerns
• Sound knowledge and experience of successful multi-agency working
• Understanding of the public sector
• Understanding of the wider healthcare community, including primary care
• Understanding of the principles of Integrated Care
• Awareness of current national and local agenda and policy, in relation to health and social care, particularly around PCNs
• Awareness of factors that contribute to good health and the importance of promoting these in line with organisational public health policy.
• Understanding of how other agencies work (i.e. social services, independent and voluntary sector)
• Experience of clinical governance including audit
• Clinical knowledge and understanding of the principles of evidence-based healthcare
• Broad knowledge of General Practice

Desirable

• Clinical knowledge and understanding of the principles of evidence-based healthcare
• Broad knowledge of General Practice

Qualifications

Essential

• Qualifications:
• ESSENTIAL
• RGN/AHP Registered Professional
• Educated to degree level
• Evidence of continuous professional development

Desirable

• DESIRABLE
• Management/Leadership qualification or be willing to undertake

Skills

Essential

• Ability to communicate complex and sensitive information effectively with people at all levels by telephone, email and face to face
• To work flexibly to deliver safe and effective healthcare
• Confidence to challenge and ability to address difficult situations and articulate rationale effectively.
• Knowledge of IT systems, including the ability to use word processing skills, emails and the internet to create simple plans and reports
• Clear, polite telephone manner
• Effective time management (planning and organising)
• Demonstrate personal accountability, emotional resilience and work well under pressure
• Ability to network with multi-disciplinary colleagues

Desirable

• Demonstrates ability to improve quality within limitations of service

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).