PCN Frailty Team Nurse

G DOC Ltd; Forest of Dean; On-site; GBP 35,000 - 45,000; Part time

Job summary

A healthcare organization in the Forest of Dean is seeking a Frailty Practitioner to deliver proactive, personalized care to individuals living with frailty. The successful candidate will work closely with multi-agency teams, ensuring holistic management and promoting independence. This part-time role offers a chance to help shape the service and enhance the quality of life for patients in the community.

Qualifications

• Minimum of 2 years post-registration experience required.
• Experience managing a team and contractual requirements.
• Demonstrates empathy, respect, and kindness.

Responsibilities

• Identify moderate and severe frailty cases.
• Conduct comprehensive geriatric assessments.
• Produce and agree Personalised Care and Support Plans.

Skills

Excellent communication skills

Advanced clinical assessment skills

Knowledge of NICE guidelines

Experience in frailty identification

Ability to work under pressure

Education

Registered Adult Nurse/Registered General Nurse

Current registration with Nursing & Midwifery Council

Post-graduate training in relevant subject

Tools

SystmOne

Digital health records

Office and Outlook

Job description

We are recruiting a Frailty Practitioner to join our developingPCN. This is an exciting time to joinour PCN as the successful candidate will have the opportunity to help shape theservice alongside the Lead GP. We are looking for a highly skilled healthcare practitioner responsible for deliveringproactive, personalised care to individuals living with frailty in communitysettings. This role interfaces with primary, secondary,social care and VCSE organisations, ensuring holistic management offrailty. With a focus on prevention, the role is pivotal in the delivery of the NHSE Proactive Care Frameworkat PCN level for people living with moderate or severe frailty, workingcollaboratively with multi-agency multi-disciplinary teams (MDTs) and systempartners to enhance independence and quality of life and in turn reduce therisk of unplanned hospital admissions. Akey element of the role is to work with people living with frailty in astrength based, collaborative way that focuses on what matters to them. Although there may be some opportunities towork from home, you must be prepared to work across various locations in theForest of Dean and occasionally may be required to attend GDOCs offices inGloucester.

The post holder will work closelywith the PCN Frailty Team and the PCN Leadership team including the ClinicalDirector, Business Manager, Digital Transformation and Practice Leads.

Approx 20 hours per week. Applications may close early depending on response.

Main duties of the job

Moderate and Severe Frailty

Case Identification using eFI/Personal Proactive Whiteboard

Triage patients and complete acomprehensive geriatric assessment (CGA) where appropriate

Producing PersonalisedCare and Support Plan (PCSP) and agree with patient/Carer

Dementia Co-diagnosis

Coordinate and lead MDTmeetings

General

Leadership and supportto the Care Coordinator and Frailty Team Administrator

Clinical assessment,diagnosis, and case management of people living with frailty in the communityusing agreed standardised tools and templates

Support the development of frailty awareness and skills for otherpractitioners, carers, and patients

Contribute to the design, implementation, and evaluation of frailtypathways and services

Identify and manage clinical risks

Collect andanalyse data to support risk stratification, use of the Personalised Proactive Whiteboard, monitoring outcomes

See job description and Functions Overview documents for further information

The job is primarily working with practices in the Forest of Dean(Blakeney, Coleford, Lydney, Yorkley and surrounding areas) and you will berequired to travel independently between practices

You will be required to be immunisedin compliance with Green Book (link attached) and NHS recommendations for your role(unless medically exempt), including immunisations against Covid.

The Care Quality Commission requires us to havea complete employment history from the age of 16, including explanations forany gaps in employment

About us

The West Forest of Dean PCN is hosted by, and core team staff employedby GDOC LTD.

G DOC LTD is owned by all the GP Practices in Gloucestershire; thePractices are our shareholders.

We operate on a not-for-profit basis: any profits are redistributed intoprimary care in Gloucestershire.

We are a limited company run by a Board of Directors, most of whom are experiencedlocal GPs.

We run a number of GP practices, as well as some other services for thewhole county.

In Gloucester we run 9,500 patients at Gloucester Health Access Centre/MatsonLane (9,500 patients) and Partners inHealth (12,400).

In the Forest of Dean, we run two practices, both of which aredispensing: Lydney (7,500 patients), and Dean Medical Practice (16,800patients).

Our countywide services include:

G DOC is running a Covid Medicines Service to help and support thehigh-risk patients in Gloucestershire.

Over 17,000 primary care appointments each year at Gloucester HealthAccess Centre for patients who may need to be seen the same day when their ownpractice is already full, or who do not have a registered GP. GHAC is open8am8pm, 365 days a year.

By joining us, you'll be part of an organisation thatputs people first supporting staff wellbeing, professional development, and acollaborative culture. You'll benefit from the stability, support, and careeropportunities of a larger organisation, while still working in close-knit,community-focused teams.

Job responsibilities

Moderate and Severe Frailty

Case Identification:

UseeFI/Personal Proactive Whiteboard to identify list of potentialpatients living with moderate or severe frailty, supported by sub-cohortanalysis, with the aim of identifying the highest risk patients

Holistic Assessment:

Providesupport to the Frailty Team Administrator to ensure the self-assessmentquestionnaire process is carried out effectively and to a high-quality standard

Triagepotential patients to determine which will receive a comprehensive geriatricassessment (CGA)

Determinewhat action to take with those patients who do not receive a CGA and ensurethose actions are undertaken

UndertakeCGAs as determined for relevant patients, inputting information into thedigital template and ensuring they are given a Rockwood Score. Draw in clinical support as required from thePCN Frailty Teams GP with an interest in Frailty for those patients with ahigher acuity of need

Personalised Care and SupportPlanning:

Ensurea Personalised Care and Support Plan (PCSP) is produced and agreed with the relevant patient and any carer/family, along with a ReSPECT plan

Coordinated and MultiProfessional Working:

Ensure close multi-professional andmulti-agency working, especially with other members of the local IntegratedNeighbourhood Team(s), to facilitate the delivery of each patients PCSP

Continuity of Care including reviews

Support the Care Coordinator to ensureregular review of patients take place as planned and agreed according to theindividual needs of the person and /or following trigger events such ashospital admission

DementiaCo-diagnosis

Determine the frequency of MDT meetings,depending on demand; keep under regular review

Support the Frailty Team Administratorto ensure all post MDT meetings are carried out in a timely and effectivemanner

General

Leadership:

Provideleadership and support to the Care Coordinator and Frailty Team Administrator

ClinicalLeadership: Provide clinical assessment, diagnosis, and case management ofpeople living with frailty in the community using agreed standardised tools andtemplates. Responsible for frailty team carecoordinators, frailty team administrators, managing caseloads and ensuring theappropriate allocation of personnel and tasks to team members

Partnership Working: Build and maintain effective workingrelationships with GPs, acute and community hospitals, Adult Social Care,voluntary sector organisations, and other community services to deliverintegrated care

Care Coordination: Ensure seamless transitions of care and continuity through proactivecase management and liaison with all relevant stakeholders

MDT Coordination: Lead and participate in MDT meetings, ensuring collaborative careplanning and shared decision-making across system partners

Education and Training: Support the development of frailty awareness andskills for other practitioners, carers, and patients

Service Development: Contribute to the design, implementation, andevaluation of frailty pathways and services

Risk Management: Identify and manage clinical risks, including falls, polypharmacy, andcognitive decline

Patient Advocacy: Promote shared decision-making and ensure care aligns with patientsvalues, goals and what matters to them

Data and Audit: Collect and analyse data to:

support risk stratification and segmentation of thepatient cohort,

enable use of the Personalised Proactive Whiteboard for care coordination,

monitor outcomes and measure impact, supportquality improvement and inform commissioning conversations

Other responsibilities

Applying PCN policies, standards andguidance;

Contributing to the teaching and training of trainees,new employees and employees who are undertaking training;

Awareness of and compliance with all relevantG DOC policies/guidelines for your role, e.g. prescribing, confidentiality,data protection, health and safety

Contributing to evaluation/audit and clinicalstandard setting within the organisation as applicable to your role;

Attending training, meetings and othermeetings and events organised by the Practices, PCN, or other agencies such asthe ICB, where appropriate;

Contributing to audits and written returns toensure that the PCN meets quality standards and receives the designatedfunding, as appropriate to your role;

Treating colleagues with courtesy andrespect;

Complying with G DOCs values, and the valuesof your PCN/team.

Confidentiality

Comply with the Confidentiality Agreement.

Health & Safety

Under the Health and Safety at Work Act 1974,you have a personal responsibility to have regard to your own and otherssafety.

You should familiarise yourself with fireexits at all sites where you work, and the action that you should take in theevent of a fire.

Personal alarms are available from G DOC forall GPs, wherever you are working. Yoursite induction should cover local procedures for summoning external help.Please ensure you familiarise yourself with these local procedures.

You must comply with site Health and Safetyprocedures, including those that concern clinical waste, use of hazardoussubstances, and the use and disposal of sharps.

Health and safety hazards should be reportedto the Practice Manager.

You should dress appropriately andprofessionally. To reduce the risk ofsharps injuries, shoes should be closed (not open sandals).

You must ensure that your car is insured forcommuting and home visits.

GPs in Gloucestershire have been the victims of serious & sustainedstalking and violence. You should notgive anyone outside the PCNinformation about when and where colleagues will beworking. Refer any queries about rotas etc to the Practice Manager or GDOC. Be aware that stalkers may haveknowledge of the local healthcare system and sound very plausible

Working conditions

Frequent, prolonged VDU use

Time-pressured environment

High levels of accuracy and attention todetail essential at all times

Exposure to distressing situations andwritten material

Safeguarding

Safeguarding is everyones responsibility. Even staff who do not routinely have contactwith patients may become aware of a safeguarding concern. You will

Ensure you arefamiliar with G DOCs safeguarding procedures

Report allconcerns promptly, following the safeguarding procedures

Ensure thatyou maintain an appropriate level of safeguarding training for your role

Contribute to meetings and other safeguarding processes, as appropriateto your role

Equality and Diversity

You will support the equality, diversity andrights of patients, carers and colleagues, to include:

Acting in a way that recognises theimportance of peoples rights, interpreting them in a way that is consistentwith PCN procedures and policies, and current legislation;

Respecting the privacy, dignity, needs andbeliefs of patients, carers, and colleagues.

Quality and Patient Safety

You will strive to maintain quality withinthe PCN, and will:

Alert other team members to any concernsabout clinical governance or quality and risk; participate in Significant EventAnalysis reviews

Assess own performance and takeaccountability for own actions, either directly or under supervision;

Contribute to the effectiveness of the teamby reflecting on own and team activities and making suggestions on ways to improve and enhance the teams performance;

Work effectively other agencies to meetpatients needs;

Effectively manage own time, workload andresources.

Avoid working if you are impaired from doingso safely or effectively, for example due to illness.

If relevant to your role, ensure that anynecessary handover and follow up arrangements for patients have been made.

Inform your line manager if you have concernsabout a colleague that might affect patient safety

Inform your line manager of any complaints orsignificant events that have arisen from your work for G DOC.

Participate in investigations of anycomplaints or significant events, if asked to do so.

Inform your line manager immediately if youhave been charged with any criminal offence.

If you are in a regulated profession (e.g.nurse, doctor, pharmacist, accountant).

Comply with your regulators guidance.

Inform your line manager immediately, if youare under investigation by your regulator.

Inform your line manager immediately, if you have any restrictions orconditions imposed on your practice by your regulator

Personal/Professional Development:

You will ensure that your mandatory training remains up to date.

You will participate in any training programme implemented by the PCN aspart of this employment, such training to include:Participation in an annual individualperformance review, including taking responsibility for maintaining arecord of own personal and/or professional development

Taking responsibility for own development, learning and performance anddemonstrating skills and activities to others who are undertaking similar work

Communication

You should recognise the importance ofeffective communication within the team and will strive to:

Communicate effectively with other teammembers, including through use of email, TeamNet and other agreed communicationchannels;

Checking your email and TeamNet every workingday;

Communicate effectively with patients andcarers;

Recognise peoples needs for alternative methods of communication andrespond accordingly i.e. signing and use of telephone and face-to-facetranslators

Person Specification

Experience

• Minimum of 2 years post-registration experience
• Broad knowledge of General Practice
• Experience of managing a team, including direct reports
• Experience of delivering contractual requirements e.g. KPIs, QOF
• Clear, polite telephone manner
• Polite and confident
• Flexible and cooperative, motivated
• High levels of integrity and loyalty
• Demonstrates empathy, respect, and kindness in all interactions
• Collaborative and able to work effectively across disciplines and organisations to deliver joined-up care
• Person centred (Prioritises the individuals needs, preferences, and dignity)
• Innovative: Seeks out and applies evidence-based practices and new models of care
• Takes responsibility for clinical decisions and service outcomes
• Engages in continuous professional development and reflective practice
• Promotes equality, diversity, and cultural competence in care delivery
• Able to use own initiative but also know when to seek assistance
• Ability to work under pressure

Skills

• Excellent communication skills (written and oral)
• Advanced clinical assessment and diagnostic skills, particularly in geriatric and frailty syndromes
• Knowledge of national standards that inform practices e.g. NICE guidelines
• Expertise in frailty identification and screening tools (e.g. Clinical Frailty Scale, eFI).
• Knowledge of clinical and information governance as appropriate to role
• Sound understanding of long-term condition management, rehabilitation and end-of-life care
• Proven ability to work effectively within MDTs and across organisational boundaries
• Understanding of personalised care, wider determinants of health and equality, diversity and inclusion
• Ability to engage with and enable people, families and carers using health coaching approaches
• Ability to enable efficient multi-agency working with practitioners across the system adopting a team of teams approach, especially with the local Integrated Neighbourhood Team
• Competence in using digital health records and remote monitoring tools
• Willing to become competent in use of SystmOne if not already
• Competent in the use of Office and Outlook
• Ability to follow policy and procedure
• Able to identify and resolve risk management issues according to policy or protocol
• Ability to assess, implement and evaluate a programme of care
• Effective time management (planning and organising)
• Ability to work as a team member and autonomously
• Good interpersonal skills
• An ability to drive, current UK driving licence and daily access to a vehicle
• Competent in use of SystmOne
• Understanding of the wider determinants of health, including social, economic and environmental factors and their impact on communities

Qualifications

• Registered Adult Nurse/Registered General Nurse or other qualification recognised by the NMC as equivalent
• Current registration with Nursing & Midwifery Council
• Post-graduate training in a relevant subject

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.