Frailty Nurse - INT Frailty Team

The Methodist Church in Britain; Par; On-site; GBP 36,000 - 46,000; Full time

Job summary

The Methodist Church in Britain is seeking a Frailty Nurse for a 12-month fixed-term post in Bosvena Health's Integrated Frailty Team, working across the Integrated Neighbourhood with social care, community partners and voluntary sector providers. The role focuses on comprehensive geriatric assessment and case management of complex care packages, with urgent referrals for frail, housebound and long-term-condition patients.

Driving licence and vehicle are required.

Qualifications

• Understanding the needs of older patients in acute and community settings.
• Experience assessing common admission conditions such as falls, UTI, LRTI, delirium, dementia, heart failure and COPD/asthma exacerbations.

Responsibilities

• Respond to urgent referrals from patients, carers and the MDT.
• Assess, diagnose, plan, organise and review complex care packages, including case conferences.
• Case manage and coordinate packages of care with adult social care.
• Provide evidence-based care in line with national and organisational policy and individual care plans.
• Undertake comprehensive risk assessments to protect patients, carers and professionals.
• Work with Occupational Health on assessments, including equipment provision and safe use.
• Support care homes with weekly check-ins, reviews of clinical priorities and new residents, and end of life and escalation planning.
• Arrange and deliver structured medication reviews with the Pharmacy Technician, including remote consultations.
• Identify frail patients for Comprehensive Geriatric Assessment using eFI or Rookwood score, and review housebound patients annually.
• Keep accurate, confidential records and oversee record standards through audit or peer review.
• Report incidents and comply with infection control and safeguarding policy.
• Supervise and support student nurses, develop the team and work towards Independent Prescriber status.

Skills

Older patient care

Geriatric assessment

Care planning

Advanced care planning

Prioritisation

Communication skills

Job description

A 12-month fixed-term Frailty Nurse post in Bosvena Health's Integrated Frailty Team, working across the Integrated Neighbourhood with social care, community partners and voluntary sector providers. The role centres on comprehensive geriatric assessment, case management of complex care packages and urgent referrals for frail, housebound and long-term-condition patients. It also supports nursing and residential homes, including medication reviews and end of life planning, within an MDT. Fit depends on a driving licence and vehicle, which the role requires.

What the job involves

• Respond to urgent referrals from patients, carers and the MDT
• Assess, diagnose, plan, organise and review complex packages of care, including case conferences
• Case manage and coordinate packages of care with adult social care
• Provide evidence-based care in line with national and organisational policy and individual care plans
• Undertake comprehensive risk assessments to protect patients, carers and professionals
• Work with Occupational Health on assessments, including equipment provision and safe use
• Support care homes with weekly check-ins, reviews of clinical priorities and new residents, and end of life and escalation planning
• Arrange and deliver structured medication reviews with the Pharmacy Technician, including remote consultations
• Identify frail patients for Comprehensive Geriatric Assessment using eFI or Rookwood score, and review housebound patients annually
• Keep accurate, confidential records and oversee record standards through audit or peer review
• Report incidents and comply with infection control and safeguarding policy
• Supervise and support student nurses, develop the team and work towards Independent Prescriber status

What’s required

Experience

• Understanding of the particular needs of older patients in acute and community settings
• Experience assessing common admission conditions such as falls, UTI, LRTI, delirium, dementia, heart failure and COPD or asthma exacerbations

Skills & knowledge

• Ability to prioritise patients for assessment and management by health status and need, referring for specialist care as needed
• Developing person-led single geriatric care plans with patients and relatives
• Initiating advanced care planning in line with end of life strategy and NICE guidance

Checks & eligibility

• Driving licence and vehicle

Nice to have

• Autonomous practitioner providing expert case management for care home and frail patients with acute or intensive needs
• Coordinating assessments and treatment for frail adults under the supervision of the Clinical Frailty lead
• Gathering and interpreting information from IT systems, performing tests and analysing results using Single Assessment Pathway
• Facilitating person-led early discharge plans with hospital MDT and discharge teams
• Proactively identifying patients who would benefit from case management to avoid admission
• Identifying, assessing and fully documenting CGA with collateral history, and formulating a plan
• Communication skills for cognitive and mental health assessment, and sustaining relationships across health and social care
• Enhanced care planning for end of life patients and completing a Treatment Escalation Plan