PCN Frailty Nurse

Job description

Job responsibilities

Undertake clinical nursing practice using expert knowledge and clinical skills to deliver holistic care to patients living in their own home or care home.

Collaborate closely with GPs and work independently to deliver safe, effective care to frail and housebound individuals, including those residing in care homes.

Promote / support health & wellbeing, helping patients to remain independent and well at home.

Facilitate patient education, self-management of disease, and behaviour modification.

Undertake annual review of patients understanding and ability to self-manage

Conduct thorough person-centred needs assessment to develop care plans for each patient.

Represent individuals and families interests when they are not able to do so themselves.

Maintain and regularly update a comprehensive register of frail patients, utilising clinical frailty scoring tools to assess and monitor levels of frailty.

Initiate the process of diagnosis with patients suspected to have a chronic disease e.g., diabetes, COPD, asthma, IHD referring to other clinical staff as appropriate.

Proactively manage long term conditions.

Accurately update patient records on SystmOne. All documentation must be timely, relevant, and clearly reflect the care provided.

Directly admit patients to secondary care hospital in acute medical need.

Promote clear communication with the health care team and support medication management.

Communicate effectively with other healthcare professionals and make appropriate referrals to ensure coordinated, multidisciplinary care.

Build and communicate therapeutic working relationships with a wide array of statutory and voluntary organisations for the benefit of patient care and facilitates good working relationships.

Attend multidisciplinary team (MDT) meetings, fostering effective working relationships with health, social care, and third-sector partners to ensure a seamless, integrated response for patients with complex needs or long-term conditions.

Work flexibly across various healthcare settings, including surgeries, home visits, and community.

Actively participate in clinical, PCN and practice meetings as required.

Participate in team meetings, audits, and data collection for improving patient care.

Support HCAs / Care Coordinators in delivering high-quality care to frail and housebound patients.

Provide expert clinical advice and support to patients, carers, and colleagues, maintaining high standards of professional practice and clinical excellence.

Operate in line with clinical protocols and guidelines, ensuring professional, compassionate support for patients, families, and carers - using resources responsibly and efficiently.

Contribute to service development by creating and implementing innovative models, methods, and practices to enhance primary care services for the frail population.

Regularly communicate service-related information to the broad spectrum of staff within the PCN and its practices.

Ensure compliance with practice CQC requirements and maintain accurate documentation.

Work within all relevant PCN practice policies and procedural guidelines e.g., infection control, chaperoning, risk management.

Contribute to PCN practice targets both local and national

Contribute to disease registers.

Keep up to date with schemes and contractual agreements by liaising with Practice Managers, GPs and Integrated Care Board.

Develop own knowledge and practice to meet objectives/changes in service, through attendance on study days, self-directed learning, and reflection on practice.

Undertake all mandatory training required for the role

Participate in our appraisal system, matching organisational aims with individual objectives Maintain the highest standards of conduct and integrity.

Person Specification

Qualifications

Essential

• Nursing qualification
• NMC registration

Desirable

• Experience of working in Primary Care

Experience

Essential

• Experience of working in a nursing team

Desirable

• Experience of working in Primary Care and or General practice
• Systmone experience
• Experience of working with patients on the Frailty register
• Experience carry out home visits
• Long term condition qualification or experience. Asthma, COPD, Diabetes, Heart disease

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

Imp Federation Ltd

Address

Commerce House Chamber Of Commerce Commerce House

Lincoln

LN2 2WJ

Employer's website

http://imphealthcare.co.uk/ (Opens in a new tab)