Frailty Nurse

Selby Town Pcn; Selby; On-site; GBP 30,000 - 46,000; Full time

Job summary

Selby Town PCN is seeking an experienced Registered Nurse with a frailty background to join the Ageing Well 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, psychological and social needs and agree individualised care plans.

Qualifications

• Registered Nurse with Nursing and Midwifery Council (NMC) registration.
• Nursing degree or diploma.
• Evidence of meeting PREP requirements.
• Experience mentoring or supporting learners.

Responsibilities

• Visit clients in their usual place of residence to assess frailty.
• Assess health needs of frail patients and identify long-term conditions.
• Undertake and coordinate Comprehensive Geriatric Assessments (CGA) and develop care plans.
• Provide clinical leadership and support to care coordinators within professional boundaries.
• Participate in MDT meetings and collaborate with the multidisciplinary team.
• Plan, implement and evaluate person-centred care and individualised CARE plans.
• Contribute to education and staff development in Frailty and Dementia.

Skills

Communication skills

Mentoring experience

Autonomous practitioner

Education

NMC registered nurse

Nursing degree/diploma

PREP requirements

Job description

Job summary

We are looking for an experienced Nurse with a background in frailty to join our innovative Ageing Well 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 agree individualised care plans.

This is an exciting opportunity for an enthusiastic, motivated Registered Nurse, working closely with our O/T, physio & care coordinators to provide proactive care for the moderately and severely frail. This role is integral to the assessment and management of patients living with frailty to allow the best access to care and support. You will be an autonomous practitioner 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 full driving licence & access to a vehicle daily.

Main duties of the job

The successful candidate should be an experienced practitioner who will work in partnership with other health professionals in supporting frail patients and providing holistic patient care. They will act within their professional boundaries and competencies, assessing, planning, implementing and evaluating patient care.

They will participate in MDT meetings to discuss patients that the Ageing Well Team are supporting. As a result, they must have high level communication/interpersonal skills to negotiate & establish collaborative partnerships 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 PCN works over four practice sites (Beech Tree Surgery, Escrick Surgery, Posterngate Surgery and Scott Road Medical Centre) a local voluntary sector site & our local community hospital.

The PCN has a Clinical Director, two Clinical Lead GPs and is managed by the PCN Operations Manager & Business Manager. We work in increasingly collaborative partnerships across several workstreams, which include important priority areas of mental health, frailty, urgent care and health inequalities. Our team consists of a diverse multi-professional workforce which includes pharmacists, MSK practitioners, mental health workers, care coordinators, social prescribing link workers, a frailty therapy team, an urgent care coordinator, UCPs, paramedics, ACPs, a transformational lead, a digital lead, health & wellbeing coach.

Job responsibilities

• To visit clients who meet the Frailty assessment criteria within their usual place of residence.
• To assess and identify the health needs of patients who are frail and who may have long-term conditions.
• To undertake and coordinate Comprehensive Geriatric Assessments (CGA), within professional competence, covering physical health, medicines, cognition, mood, mobility, falls risk, nutrition, continence, functional ability, social circumstances and future care wishes.
• To use CGA findings to develop, document and review person-centered, strengths-based care and support plans with patients, carers and the multidisciplinary team, escalating clinical concerns appropriately.
• To provide clinical leadership, guidance and support to care coordinators, including advice on patient care, risk management, escalation and effective multidisciplinary working within agreed professional boundaries.
• 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 Personalised Care and Support Plans.
• Develop disease specific patient information and education to support patients self care.
• Participate in education & staff development, including specialised CPD relevant to Frailty and Dementia and actively participate in regular supervision.

Person Specification

Qualifications

Essential

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

Desirable

• N/A

Experience

Essential

• 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

Desirable

• 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.

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. Applicants must have current UK professional registration. For further information please see NHS Careers website (opens in a new window).