PCN Frailty Specialist Nurse

Job description

Job responsibilities

Four Counties Primary Care Network are establishing a collaborative multi-disciplinary service providing proactive Primary Care to our large Care Home population in Stamford, Bourne and villages. We are delivering four main workstreams on behalf of the 2 GP practices as part of the Enhanced Health in Care Home DES:

1. Enhanced primary care support

2. Multi-disciplinary team (MDT) support

3. Falls prevention, Reablement, and rehabilitation

4. High quality palliative and end-of-life care, Mental health, and dementia care

We are looking to expand our team with an enthusiastic Nurse, with a special interest in frailty, and passion for elderly care and multidisciplinary team working. You will be working flexibly across all four workstreams, but with a main focus on advanced care planning and providing proactive preventative care.

You will also be responsible for the following tasks:

• Lead on the delivery of the Enhanced Health in Care Homes DES, including providing weekly care home rounds supporting proactive Person Centred Care Planning
• Person Centred Care Planning- By having aperson-centred careapproach it gives people more choice and control in their lives by providing an approach that is appropriate to the individual's needs. It involves a conversation shift from asking 'what's the matter with you' to 'what matters to you'
• Early identification and recognition of deterioration to include proactive care and escalation planning
• Full Comprehensive Geriatric assessment for residents that have moderate to severe Frailty to support the coordination of care with community and urgent care services
• Understand the degree of frailty, mild moderate or severe and the 6 frailty syndromes enabling the correct proportionate response to a patient need
• To support proactive, anticipatory and advance care planning using an agreed set of validated, evidence based assessment tools to help identify the degree of need, e.g. Edmonton, SPICT/SPICT4ALL, Respect, RNT, CGA, EPaCCS
• Monitor and lead improvements to standards of care through, supervision of practice, clinical audit, evidence-based practice, teaching and supporting professional colleagues and the provision of skilled professional leadership.
• Identify and support educational opportunities to work with care homes, for example completion of Respect Documents, hydration and nutritional support and good oral health care.
• Working with other practitioners and agencies within the Primary Care Network and local system as necessary to develop patient specific treatment plans and ensure Care Pathways are utilised. Attendance through MDT working
• Provide continence support and management in conjunction with homes and community services
• Support necessary vaccination campaigns within care homes
• Provide high quality mental health and dementia care, offering support and guidance to homes, working in collaboration with community services
• Provide wound care support and advice in conjunction with homes and community services
• Undertake high standards of clinical record keeping including electronic data entry and recording of patient records

Person Specification

Qualifications

Essential

• Recognised professional degree, Registered with NMC

Desirable

• Post registration course in palliative care, dementia, long term conditions or frailty

Experience

Essential

• Minimum 5 years post registration experience, Experience with Palliative and End of life Care, Experience with Dementia Care, Experience in Personalised Care Planning, Experience in Frailty identification and Comprehensive Geriatric Assessments, Experience working in a multidisciplinary team

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.

UK Registration

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

Employer details

Employer name

Lakeside Healthcare Group

Address

Lakeside Healthcare

Ryhall Road

Stamford

Lincolnshire

PE9 1YA

Employer's website

https://www.lakesidehealthcaregroup.co.uk (Opens in a new tab)