INT Home Team Frailty Nurse 1 year fixed term with possible extension

NHS; St. Austell; On-site; GBP 30,000 - 40,000; Full time

Job summary

A leading healthcare provider is seeking a Frailty Nurse to support frail patients in the community. The role involves assessing, planning, and implementing care plans while working closely with multidisciplinary teams to improve patient outcomes. Candidates should have a nursing degree, relevant experience, and excellent communication skills.

Qualifications

• 2+ years experience in nursing or equivalent clinical qualification.
• Eligible to work in the UK.

Responsibilities

• Lead the Home Team Frailty program for the St Austell Integrated Neighbourhood Team.
• Assess, plan, implement and evaluate specialist treatment and care.
• Provide highly specialist advice regarding patient management.

Skills

Communication

Flexibility

Self-motivated

Organizational skills

Education

Degree in Nursing

Job description

INT Home Team Frailty Nurse 1 year fixed term with possible extension

The fundamental roleof the post holder is to meet the primary care needs of an identified group ofpeople identified as frail and needing further support in the community. Thepost holder will liaise with SAHC clinicians and other community health and socialcare providers to meet the identified needs of these patients.

Main duties of the job

This workload will involve reviewing medical issues and current problems,completing medication reviews and dementia screening, developing a treatmentescalation plan, ensuring all appropriate assessments are completed anddeveloping and implementing an appropriate individualised plan of care. Theclinician will be expected to visit patients where required.

The service is designed to achieve the following:

• A fall in ambulance hospital journeysrequired by residents of St Austell and Mevagissey who are deemed as frail
• A drop in hospitalattendances for these residents
• A reduction in hospitaladmissions for these residents
• Improved Health and social caresupport for these residents and their carers to help them to keep at home andavoid hospital admission.
• Joined up pathways with acutetrust, ambulance service, community services, social services, communityvoluntary services and end of life care to support admission avoidance.

Please note you will be required to drive across the St Austell andMevagissey area

About us

StAustell Healthcare (SAH) formed in May 2015 comprising the four formerpractices in St Austell. The GP surgery in Mevagissey joined in 2021. We have atotal list size of 37,400 patients. Were a Primary Care Network (PCN) in ourown right and winner of NAPC Primary Care Home award for 2019/20. The practiceoffers unparalleled peer support, the chance to influence the future ofcommunity based medical care and the opportunity to earn well alongside anexperienced and friendly team. We have a full range of ARRS roles includingCPNs, Physio, Paramedics, Pharmacists and Social prescribers amongst others.

Over2024, six Integrated Neighbourhood Teams (INTs) were established within CentralCornwall ICA, aligning with the six Primary Care Network (PCN) footprints.These teams bring together multidisciplinary professionals across health,social care, and community services to deliver integrated and equitable care.Phases 1 and 2 of development focused on relationship-building and initialcollaboration, supported by the National Association of Primary Care (NAPC).

StAustell PCN has been chosen as one of 2 INTs in our area to be a Wave 1Integrated Neighbourbhood Team and expand this concept further into anoperational model delivering on key outcomes.

Job responsibilities

Clinical Responsibilities and Requirements

• To lead the Home Team Frailty program for the St Austell Integrated Neighbourhood Team.
• To assess, plan, implement and evaluate specialist treatment and care through personalised care plans to people on an allocated caseload; promoting independence and autonomy; working within a multi-disciplinary team.
• Supporting the Frailty GP in improving diagnosis and screening of people with dementia within the care home, this will be by the review of all care home residents.
• Act as an expert practitioner, demonstrating clinical competence and a sound knowledge base.
• Undertake consultations with patients including visiting in their own home or a care home environment.
• Assess patients with a range of acute, non-acute and chronic medical conditions.
• Advance own clinical knowledge, skill and competence based on current evidence through advanced educational programmes.
• Completing and sharing advanced care plans
• Partnership working with other providers to deliver seamless joined up care.
• Reviewing and making clinical decisions, including prioritisation of need.
• Provide highly specialist advice to others regarding the management and care of patients/service users.
• To demonstrate clinical effectiveness by use of evidence-based practice and outcome measures.
• Plan, implement and review health improvement programmes in a range of settings.
• Recognise, assess, and manage risk across the immediate and wider working environment and make appropriate decisions autonomously, ensuring statutory requirements are met.
• To be responsible for patient safety through knowledge of systems, legal requirements and understanding of litigation.
• To communicate effectively in verbal and written form in the exchange of highly complex, sensitive or contentious information in difficult situations using de-escalation, mediation, resolution and professional Duty of Candour.
• To evaluate care, taking appropriate action leading to improvement in quality standards through clinical audit, root cause analysis and dealing with complaints.
• Provision of support to carers considering what can put in place to support that persons mental health and wellbeing, by the use of tools to identify deterioration in wellbeing and mental state.
• Liaison between local organisations such as volunteering etc to provide services that can support the delivery of care within the patients own home.
• Setting up, referral to and attendance at MDTs involving a range of health and care professionals, from one or more organisations, working together to deliver comprehensive patient care. The benefits of such an approach can include improved health outcomes, enhanced satisfaction for the individual and a more efficient use of resources.
• Line manage team members

Professional

• Adhere to own professional body requirements and at all times work within the scope of professional practice.
• Ensure that professional practice adheres to organisational policies, procedures and guidelines.
• Maintain a professional manner and act as a role model and mentor for junior staff including trainees and student nurses.
• Maintain confidentiality with regard to information pertaining to patients and staff.
• Ensure that the service interfaces with all other departments in a professional and productive manner, providing an effective service to partner organisations and other service providers.

Person Specification

Qualifications

• Degree in Nursing or equivalent clinical qualification with NHC registration and 2+ years experience
• Eligible to work in the UK
• Meets DBS requirements
• Prescribing qualification or commitment to one

Experience

• Frailty management in an acute setting.
• Frailty management in a community setting
• Creation/Review of care plans
• Experience of working to protocols or guidelines
• Primary care experience
• Experience of lone working
• Knowledge of social services and voluntary sectors
• Experience in visiting patients in own home
• Knowledge of UK NHS General Practice
• Excellent written and verbal communication skills
• Good organisational skills

Motivation

• Ability to work as part of a team
• Flexibility
• Self-motivated and self-managing
• Full UK driving licence and vehicle access
• Willingness to undergo additional training, education and mentoring to develop and maintain clinical skills

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.