Frailty Nurse

Faversham Medical Practice; Swanley; On-site; GBP 32,000 - 46,000; Full time

Job summary

Faversham Medical Practice is seeking a Frailty Nurse to lead proactive care reviews and structured medication reviews for frail patients. You will perform advanced care planning discussions and geriatric assessments, coordinating with GPs and MDT members to improve patient outcomes.

You will conduct remote and in-practice frailty reviews, support QOF work, and maintain high-quality records. A strong emphasis on safeguarding and professional development is essential.

Qualifications

• English and Maths GCSE grade C or above or equivalent.
• Registered General Nurse with current NMC registration.
• Proven commitment to ongoing professional development.
• Experience dealing with the public and patients.
• Experience working with frail, elderly or housebound patients.
• Experience using Microsoft Office software.

Responsibilities

• Support advance care planning discussions and frailty reviews in care homes, patients' homes, or GP surgeries.
• Conduct regular reviews for eligible residents, including care home residents and housebound individuals.
• Contribute to QOF work and chronic disease reviews.
• Engage in MDT meetings and collaborate with GP colleagues and practice staff.
• Maintain accurate clinical records and participate in quality improvement initiatives.

Skills

Public & patient communication

Frailty care experience

Office software

Education

English and Maths GCSE (Grade C or above)

Registered General Nurse (NMC)

Tools

EMIS software

Job description

Job summary

This role is centred on proactive and reactive care reviews, including advance care planning discussion, comprehensive geriatric assessments and, if appropriate, structured medication reviews. The role aims to improve outcomes for frail patients, reduce avoidable hospital admissions, and support quality improvement across the network.

Main duties of the job

The role involves carrying out advance care planning discussions, comprehensive geriatric assessments and structured medication reviews (SMRs). These duties will be carried out in care homes, patients own homes or in the GP surgery.

You will:

• Conduct regular reviews for eligible patients, including patients in care homes and house bound patients
• Support QOF work relating to the patients
• Conduct In-practice frailty reviews for patients attending appointments
• Conduct remote consultation frailty reviews where appropriate

You will work closely with the Frailty & Care Home Lead GPs and be supported by a Multi-Disciplinary Team (MDT). The role includes attendance at MDT meetings, as appropriate.

About us

Faversham Medical Group consists of 2 GP surgeries; Faversham Medical Practice and Newton Place Surgery. We also run an Urgent Treatment Centre based at Faversham Health Centre.

We are a friendly and supportive team.

Faversham is a beautiful, historic market town. It is close to the vibrant city of Canterbury; just 60 miles from London and yet within easy reach of attractive coastline areas and beaches.

Job responsibilities

Clinical Responsibilities

The post holder will:

• Ensure that all eligible residents in aligned care homes are identified and offered both seasonal and routine vaccinations
• Contribute to anticipatory care planning and personalised care discussions
• Provide remote consultations where clinically appropriate
• Deliver in-practice frailty reviews for patients attending appointments
• Recognise professional limitations and elevate appropriately to GP or MDT colleagues
• Maintain accurate, contemporaneous and high-quality clinical records in appropriate clinical system

Care Home & Frailty Service Delivery

• Build effective working relationships with care home and PCN staff
• Contribute to reducing avoidable admissions and improving continuity of care
• Participate in service development and refinement of frailty pathways

QOF & Quality Improvement

The Frailty Nurse will:

• Support QOF-related work for patients
• Contribute to chronic disease reviews and monitoring
• Ensure accurate clinical coding and documentation
• Participate in audit and quality improvement initiatives, where appropriate

Multidisciplinary Working

• Work collaboratively within a MDT
• Liaise closely with the GPs
• Attend MDT meetings, as appropriate
• Contribute to coordinated, team-based patient care

Professional Responsibilities

• Maintain active NMC registration
• Work within professional scope of practice and competencies
• Demonstrate safe, evidence-based clinical decision-making
• Engage in continuous professional development
• Maintain revalidation requirements
• Uphold confidentiality, safeguarding and data protection standards

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 practice 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 practice may only be divulged to authorised persons in accordance with the practice policies and procedures relating to confidentiality and the protection of personal and sensitive data

Health & safety

• Using personal security systems within the workplace according to practice guidelines
• Awareness of national standards of infection control and cleanliness and regulatory / contractual / professional requirements, and good practice guidelines
• Responsible for the correct and safe management of the specimens process including collection, labelling, handling, use of correct and clean containers, storage and transport arrangements
• Management and maintenance of Personal Protective Equipment (PPE) for the practice including provision, ordering, availability and ongoing correct usage by staff
• Responsible for hand hygiene across the practice
• Ownership of infection control and clinically based patient care protocols, and implementation of those protocols across the practice
• Active observation of current working practices across the practice in relation to infection control, cleanliness and related activities, ensuring that procedures are followed and weaknesses / training needs are identified, escalating issues as appropriate
• Identifying the risks involved in work activities and undertaking such activities in a way that manages those risks across clinical and patient process
• Making effective use of training to update knowledge and skills, and initiate and manage the training of others across the full range of infection control and patient processes
• Monitoring practice facilities and equipment in relation to infection control, ensuring that provision of hand cleansing facilities, wipes etc are sufficient to ensure a good clinical working environment. Lack of facilities to be escalated as appropriate.
• Safe management of sharps procedures including training, use, storage and disposal
• Using appropriate infection control procedures, maintaining work areas in a tidy, clean and sterile, and safe way, free from hazards. Initiation of remedial / corrective action where needed or escalation to responsible management
• Actively identifying, reporting, and correction of health and safety hazards and infection hazards immediately when recognised
• Keeping own work areas and general / patient areas generally clean, sterile, identifying issues and hazards / risks in relation to other work areas within the business, and assuming responsibility in the maintenance of general standards of cleanliness across the business in consultation (where appropriate) with other sector managers
• Undertaking periodic infection control training (minimum twice annually)
• Routine management of own team / team areas, and maintenance of work space standards
• Waste management including collection, handling, segregation, container management, storage and collection
• Spillage control procedures, management and training
• Decontamination control procedures, management and training, and equipment maintenance
• Maintenance of sterile environments

Equality and diversity

• Acting in a way that recognises the importance of peoples rights, interpreting them in a way that is consistent with practice 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-judgmental and respects their circumstances, feelings priorities and rights.

Personal/Professional development

• Participation in an annual individual performance review, including taking responsibility for maintaining a record of own personal and/or professional development
• Taking responsibility for own development, learning and performance and demonstrating skills and activities to others who are undertaking similar work
• Comply with the nursing and midwifery council code of conduct, maintaining an up to date registration and documentation.

Quality

• Alert other team members to issues of quality and risk
• Assess own performance and take accountability for 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 recognize the importance of effective communication within the team and will strive to:

Communicate effectively with other team members

• Communicate effectively with patients and carers
• Recognise peoples needs for alternative methods of communication and respond accordingly

Contribution to the implementation of services

The post-holder will:

• Apply practice policies, standards and guidance
• Discuss with other members of the team how the policies, standards and guidelines will affect own work
• Participate in audit where appropriate

Person Specification

Qualifications

Essential

• English and Maths GCSE grade C or above or equivalent.
• Registered General Nurse (with current NMC registration).
• A demonstrable commitment to professional development.

Experience

Essential

• Experience of working in accordance with the NMC Code of Professional Conduct 2015 and The Scope of Professional Practice 1992.
• Experience of dealing with the public & patients.
• Experience working with frail, elderly or housebound patients
• Experience of Microsoft Office software.

Desirable

• Experience using EMIS software.
• Experience contributing to QOF achievement
• Experience participating in Multi-Disciplinary Team working

Essential Other

Essential

• Flexibility of working hours and ability to work at the desired times.
• Car driver and valid license and access to own transportation during working hours.
• Willingness to visit patients in their home environment if required.

Desirable

• Experience of Primary Care.

Essential Qualities and Attributes

• An understanding and acceptance and adherence to the need for strict confidentiality.
• Ability to use own judgement, resourcefulness and common sense.
• Ability to work without direct supervision and determine own workload priorities.
• Ability to work as part of an integrated multi-skilled team.
• Pleasant and articulate.
• Able to work under pressure.
• Able to work in a changing environment.
• Able to use own initiative.

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).