Job summary
As a key member of a multidisciplinary team, the PCN Frailty Nurse will play a key role in preventing avoidable hospital admissions. They will case-manage patients with frailty and long-term conditions, promoting independence and supporting individuals to live well in their own homes.
In this fast-paced and rewarding role, the PCN Frailty Nurse will be expected to work independently, exercising sound clinical judgment within the boundaries of their professional practice. They will also demonstrate a solid understanding of community services and collaborate effectively with the wider multidisciplinary team for guidance and support when needed.
Working under the guidance of the Frailty Lead GPs the Frailty Nurse will receive daily support from Frailty Care Coordinators, Clinical Pharmacists, and the wider practice team.
A valid driving licence and access to your own vehicle are essential for this role.
Main duties of the job
The PCN Frailty Nurse will work within their professional scope of practice in a general practice environment as part of our Primary Care Network.
The PCN Frailty Nurse will plan, implement and evaluate care for patients in our community, to meet patients' needs and preferences in the delivery of high-quality health care. Ensuring that the patient's needs and preferences are known and communicated at the right time to the right people, and that this information is used to guide the delivery of safe, appropriate, and effective care.
About us
Armley Primary Care Network is a forward-thinking group of
GP practices working together to enhance the health and wellbeing of the Armley
population of over 30,000 patients.
As a network our vision is collaborate to integrate care and
to work better together to meet the needs of our population. Our key priorities
as a PCN are prevention, mental health and physical/mental frailty.
We have a friendly, supportive and nurturing management
style, and you will fit into the team well if you have a committed work ethic,
enjoy working collaboratively and can work at pace.
We are dedicated to supporting the ongoing professional development of our staff.
Job description
Job responsibilities
Main Job
Responsibilities
As an integral member of the PCN Frailty Team, the Frailty
Nurse will:
-
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 both EMIS
and SystmOne systems. 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.
-
Organise and chair 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.
-
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
Knowledge, Training and Experience:
-
registered nurse with at least two years recent
primary or community nursing experience
-
experienced and up to date in blood pressure,
temperature, pulse, testing blood sugars, O2 sats, tissue/skin health, diabetic
foot checks
-
knowledge of wound care
-
recent experience working with frail / elderly
-
experience with end-of-life care/RESPECT forms
-
experience of working with care homes desirable
Confidentiality
Ensure that confidentiality is adhered to in
terms of patient information and the protection of personal and sensitive data.
Health and Safety
Identify risks involved in work activities and
undertake activities in a way that manages risks.
Actively report health and safety hazards and
infection hazards immediately when recognised.
Maintenance of general standards of cleanliness
consistent with the scope of the role.
Equality and Diversity
Act in a way that recognises the importance of
peoples rights, interpreting them in a way that is consistent with PCN practice
procedures and policies, and current legislation.
Safeguarding
Be familiar with and adhere to PCN practice
safeguarding policies, procedures and guidelines for both children and adults
at risk of abuse or neglect in conjunction with Multi-agency Safeguarding
Children and Safeguarding Adults at risk of abuse and/or neglect policy,
protocols, and guidelines.
Key Working Relationships
-
PCN Clinical Director
-
Frailty Team
-
PCN Frailty Clinical Leads
-
GPs, Practice Managers, nurses and other
practice staff
-
PCN teams: Clinical Pharmacists, Social
Prescribers, Dietician, Health and Wellbeing Coaches,
-
Providers of care including acute trusts,
independent sector and providers, neighbourhood teams, community services,
geriatricians, community matrons, community mental health services
-
Local Care Partnerships linked to the PCN
Job description
Job responsibilities
Main Job
Responsibilities
As an integral member of the PCN Frailty Team, the Frailty
Nurse will:
-
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 both EMIS
and SystmOne systems. 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.
-
Organise and chair 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.
-
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
Knowledge, Training and Experience:
-
registered nurse with at least two years recent
primary or community nursing experience
-
experienced and up to date in blood pressure,
temperature, pulse, testing blood sugars, O2 sats, tissue/skin health, diabetic
foot checks
-
knowledge of wound care
-
recent experience working with frail / elderly
-
experience with end-of-life care/RESPECT forms
-
experience of working with care homes desirable
Confidentiality
Ensure that confidentiality is adhered to in
terms of patient information and the protection of personal and sensitive data.
Health and Safety
Identify risks involved in work activities and
undertake activities in a way that manages risks.
Actively report health and safety hazards and
infection hazards immediately when recognised.
Maintenance of general standards of cleanliness
consistent with the scope of the role.
Equality and Diversity
Act in a way that recognises the importance of
peoples rights, interpreting them in a way that is consistent with PCN practice
procedures and policies, and current legislation.
Safeguarding
Be familiar with and adhere to PCN practice
safeguarding policies, procedures and guidelines for both children and adults
at risk of abuse or neglect in conjunction with Multi-agency Safeguarding
Children and Safeguarding Adults at risk of abuse and/or neglect policy,
protocols, and guidelines.
Key Working Relationships
-
PCN Clinical Director
-
Frailty Team
-
PCN Frailty Clinical Leads
-
GPs, Practice Managers, nurses and other
practice staff
-
PCN teams: Clinical Pharmacists, Social
Prescribers, Dietician, Health and Wellbeing Coaches,
-
Providers of care including acute trusts,
independent sector and providers, neighbourhood teams, community services,
geriatricians, community matrons, community mental health services
-
Local Care Partnerships linked to the PCN
Person Specification
Knowledge and Skills
Essential
- Understanding of Personalised Care
- Understanding of the wider determinants of health
- Knowledge of how the NHS works, including primary care and PCNs
- Ability to recognise/work within limits of competence, seeking advice if needed
- Understanding of the needs of older people / adults with disabilities / long term conditions particularly in relation to promoting their independence
- Basic knowledge of long-term conditions and associated complexities: medical, physical, emotional and social
- Clear, polite telephone manner
- Good interpersonal skills
- Ability to record accurate clinical notes
- EMIS and SystmOne user skills
- Proficient in MS Office and web-based services
Qualifications
Essential
- Current UK NMC registration and maintains revalidation
- Relevant nursing or health degree
- Experienced and up to date in blood pressure, temperature, pulse, testing blood sugars, O2 sats, tissue/skin health, diabetic foot checks
- Up to date vaccinations and immunisations training for Covid/Influenza
- Evidence of continual professional development
- Full UK Driving Licence
Other
Essential
- Meets an enhanced Disclosure and Barring Service (DBS) check
- Access to own transport and ability to travel across the PCN on a regular basis
Personal Qualities
Essential
- Teamwork: Work effectively and professionally within the frailty team through willingness to proactively support and assist peers and colleagues.
- Autonomous: Ability to work independently by making informed decisions based on professional knowledge and clinical judgement
- Solution Focussed: Ability to react to and face challenges or setbacks in a positive manner with a commitment to continuous improvement
- Ability to actively listen, empathise with people and provide personalised support in a non-judgemental way.
- Ability to provide a culturally sensitive service supporting people from all backgrounds and communities, respecting lifestyles and diversity
- Commitment to reducing health inequalities and proactively working to reach people from diverse communities
- Ability to support people in a way that inspires trust and confidence, motivating others to reach their potential
- Ability to communicate effectively, both verbally and in writing, with people, their families, carers, partner agencies and stakeholders
- Ability to provide motivational coaching to support peoples behaviour change
- Ability to identify risk and assess / manage risk when working with individuals
- Strong awareness and understanding of when necessary to refer people to other health professionals, when the need is beyond the scope of Frailty Nurse role
- Ability to maintain effective working relationships and promote collaboration
- Personal accountability, emotional resilience, ability to work well under pressure
- Ability to organise, plan and prioritise on own initiative, including when under pressure and meeting deadlines
- Ability to work flexibly and enthusiastically within a team or on own initiative
- Knowledge of and ability to work to policies & procedures, e.g. confidentiality, safeguarding, lone working, information governance, and health and safety
- Demonstrable commitment to professional and personal development
Experience
Essential
- Two years recent primary or community nursing experience
- Experience of working in health, social care and other support roles in direct contact with people, families or carers (in a paid or voluntary capacity)
- Experience of working within multi - professional team environments
- Experience of supporting people, their families and carers in a related role
- Experience of working with elderly or vulnerable people, complying with best practice and relevant legislation
Desirable
- Experience or training in personalised care and support planning
- Experience of data collection and using tools to measure the impact of services
Person Specification
Knowledge and Skills
Essential
- Understanding of Personalised Care
- Understanding of the wider determinants of health
- Knowledge of how the NHS works, including primary care and PCNs
- Ability to recognise/work within limits of competence, seeking advice if needed
- Understanding of the needs of older people / adults with disabilities / long term conditions particularly in relation to promoting their independence
- Basic knowledge of long-term conditions and associated complexities: medical, physical, emotional and social
- Clear, polite telephone manner
- Good interpersonal skills
- Ability to record accurate clinical notes
- EMIS and SystmOne user skills
- Proficient in MS Office and web-based services
Qualifications
Essential
- Current UK NMC registration and maintains revalidation
- Relevant nursing or health degree
- Experienced and up to date in blood pressure, temperature, pulse, testing blood sugars, O2 sats, tissue/skin health, diabetic foot checks
- Up to date vaccinations and immunisations training for Covid/Influenza
- Evidence of continual professional development
- Full UK Driving Licence
Other
Essential
- Meets an enhanced Disclosure and Barring Service (DBS) check
- Access to own transport and ability to travel across the PCN on a regular basis
Personal Qualities
Essential
- Teamwork: Work effectively and professionally within the frailty team through willingness to proactively support and assist peers and colleagues.
- Autonomous: Ability to work independently by making informed decisions based on professional knowledge and clinical judgement
- Solution Focussed: Ability to react to and face challenges or setbacks in a positive manner with a commitment to continuous improvement
- Ability to actively listen, empathise with people and provide personalised support in a non-judgemental way.
- Ability to provide a culturally sensitive service supporting people from all backgrounds and communities, respecting lifestyles and diversity
- Commitment to reducing health inequalities and proactively working to reach people from diverse communities
- Ability to support people in a way that inspires trust and confidence, motivating others to reach their potential
- Ability to communicate effectively, both verbally and in writing, with people, their families, carers, partner agencies and stakeholders
- Ability to provide motivational coaching to support peoples behaviour change
- Ability to identify risk and assess / manage risk when working with individuals
- Strong awareness and understanding of when necessary to refer people to other health professionals, when the need is beyond the scope of Frailty Nurse role
- Ability to maintain effective working relationships and promote collaboration
- Personal accountability, emotional resilience, ability to work well under pressure
- Ability to organise, plan and prioritise on own initiative, including when under pressure and meeting deadlines
- Ability to work flexibly and enthusiastically within a team or on own initiative
- Knowledge of and ability to work to policies & procedures, e.g. confidentiality, safeguarding, lone working, information governance, and health and safety
- Demonstrable commitment to professional and personal development
Experience
Essential
- Two years recent primary or community nursing experience
- Experience of working in health, social care and other support roles in direct contact with people, families or carers (in a paid or voluntary capacity)
- Experience of working within multi - professional team environments
- Experience of supporting people, their families and carers in a related role
- Experience of working with elderly or vulnerable people, complying with best practice and relevant legislation
Desirable
- Experience or training in personalised care and support planning
- Experience of data collection and using tools to measure the impact of services
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).
Additional information
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).