PCN Frailty Nurse

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

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).