Frailty Nurse

Selby Town PCN; Harrogate; On-site; GBP 32,000 - 45,000; Full time

Job summary

Selby Town PCN is seeking an experienced Registered Nurse with a background in frailty to join the AgeingWell Team across the PCN. The post holder will provide proactive, person-centred care for people living with moderate and severe frailty, including undertaking and coordinating Comprehensive Geriatric Assessments (CGA) to identify medical, functional and social needs.

This community-based role requires an autonomous practitioner with a can-do attitude, flexible approach, and a driving licence

Qualifications

• Registered Nurse with Nursing and Midwifery Council.
• Evidence of meeting PREP Requirements.
• Experience mentoring/supporting learners or ability to demonstrate mentoring skills.
• Willingness to develop skills in Advanced Care Plans and RESPECT documentation.

Responsibilities

• Visit clients who meet Frailty assessment criteria within their usual place of residence.
• To assess and identify health needs of frail patients, including long-term conditions.
• To undertake and coordinate Comprehensive Geriatric Assessments (CGA) across physical health, medicines, cognition, mood, mobility, nutrition, continence, function and social needs.
• To develop, document and review person-centred care plans with patients, carers and MDT, escalating concerns as needed.
• Provide clinical leadership and guidance to care coordinators and support multidisciplinary teamwork.
• Address identified needs of frail patients and those with long-term conditions through planned programmes of care.

Skills

Nursing registration

Frailty experience

Mentoring learners

Independent working

Education

Nursing degree

Job description

We are lookingfor an experienced Nurse with a background in frailty to join our innovative AgeingWell Team across the PCN. The post holder will provide proactive,person-centered care for people living with moderate and severe frailty,including undertaking and coordinating Comprehensive Geriatric Assessments(CGA) to identify medical, functional, psychological and social needs and agreeindividualised care plans.

This is anexciting opportunity for an enthusiastic, motivated Registered Nurse, workingclosely with our O/T, physio & care coordinators to provide proactive carefor the moderately and severely frail. This role is integral to the assessmentand management of patients living with frailty to allow the best access to careand support. You will be an autonomous practitioner who is adaptable, has aflexible can-do attitude with a passion for excellence & ability to workwell both on their own & as part of a team.

This is acommunity-based role applicants must have a full driving license & accessto a vehicle daily.

Main duties of the job

The successful candidateshould be an experienced practitioner who willwork in partnership with other health professionals in supporting frailpatients and providing holistic patient care. They will act within theirprofessional boundaries and competencies, assessing, planning, implementing andevaluating patient care.

They will participate inMDT meetings to discuss patients that the Ageing Well Team are supporting. Asa result, they must have high levelcommunication/interpersonal skills to negotiate & establish collaborativepartnerships with patients & care professionals and have enthusiasm &the ability to use their own initiative.

About us

Employed by Selby Prime Care Ltd but subcontracted to Selby Town PCN,this is a role to support patients across Selby Town PCN.

The PCNworks over four practice sites (Beech Tree Surgery, Escrick Surgery,Posterngate Surgery and Scott Road Medical Centre) a local voluntary sectorsite & our local community hospital.

The PCNhas a Clinical Director, two Clinical Lead GPs and is managed by the PCNOperations Manager & Business Manager. We work in increasinglycollaborative partnerships across several workstreams, which include importantpriority areas of mental health, frailty, urgent care and health inequalities.Our team consists of a diverse multi-professional workforce which includespharmacists, MSK practitioners, mental health workers, care coordinators,social prescribing link workers, a frailty therapy team, an urgent carecoordinator, UCPs, paramedics, ACPs, a transformational lead, a digital lead,health & wellbeing coach.

Job responsibilities

KEYRESPONSIBILTIES

To visit clients who meet the Frailty assessmentcriteria within their usual place of residence.

To assess and identify the health needs ofpatients who are frail and who may have long-term conditions.

To undertake and coordinate ComprehensiveGeriatric Assessments (CGA), within professional competence, covering physicalhealth, medicines, cognition, mood, mobility, falls risk, nutrition,continence, functional ability, social circumstances and future care wishes.

To use CGA findings to develop, document andreview person-centered, strengths-based care and support plans with patients,carers and the multidisciplinary team, escalating clinical concernsappropriately.

To provide clinical leadership, guidance andsupport to care coordinators, including advice on patient care, riskmanagement, escalation and effective multidisciplinary working within agreedprofessional boundaries.

To assess, plan, implement and evaluateprogrammes of care to address the identified needs of patients identified asbeing frail and/or those with long-term conditions.

To support the development of patientsindividual Personalised Care and Support Plans.

Develop disease specific patient informationand education to support patients self care.

Participate in education &staff development, including specialised CPD relevant to Frailty and Dementiaand actively participate in regular supervision.

Please see attached job description for full details of the role.

Other requirements

• Please see attached job description and person specification for full details.

Qualifications

• Registered Nurse with Nursing and Midwifery Council.
• Evidence of meeting PREP Requirements
• Experience of mentoring/supporting learners or ability to demonstrate the skills required for effective mentoring
• N/A

Experience

• Demonstrable nursing experience across a variety of settings
• Experience of delivering patient education and promoting self-directed care
• Experience of working with people living with frailty and long-term conditions in community or primary care settings
• Experience of working autonomously within professional boundaries and competence
• Experience of assessing, planning, implementing and evaluating person-centered care for people living with frailty
• Experience of undertaking or contributing to Comprehensive Geriatric Assessment, including physical health, medicines, cognition, mood, mobility, falls risk, nutrition, continence, functional ability and social circumstances.
• Experience of translating assessment findings into coordinated strengths-based care and support plans
• Experience of multidisciplinary working and contributing effectively to MDT meetings
• Experience of providing clinical leadership, guidance or support to care coordinators or other members of a multidisciplinary team
• Experience of identifying and managing clinical risk, escalating concerns appropriately and safeguarding adults
• Experience of using the Rockwood Clinical Frailty Scale
• Community nursing experience
• Experience of health behaviour change and/or health and wellbeing programmes
• Willingness to develop skills in Advanced Care Plans and RESPECT documentation.

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.