Frailty Practitioner

MAIN DUTIES AND RESPONSIBILITIES To participate, promote and support in the use of advanced care planning tools.(e.g. CMC) within CHS Community services To support links with the Care Home Support Team and other care providers to co-ordinate a single response and to prevent duplication of patient care. To participate in maintaining an overview of the standards of care being delivered across a defined area, instigating remedial action to improve practice as necessary. To support the Matron in actively promoting the use of telehealth and other telehealth solutions across the Alliance to prevent hospital admission Clinical To work in partnership with members of the One Croydon Programme Office and multiagency colleagues to develop person centred care planning including the use of CMC with a view to creating individualised advanced care plans for complex patients Assessment and treatment of patients during a crisis, identifying complex and specialist need and developing, implementing and evaluating programmes of care.

Facilitating early hospital discharge for patients back to care homes by providing in-reach into the acute hospital Work with a high level of autonomy, within agreed guidelines, managing undifferentiated and undiagnosed problems using advanced nursing skills by incorporating physical assessment, diagnosis and prescribing. Ensure the team delivers clinically effective care and health promotion that is evidence based. To keep accurate contemporaneous written and / or electronic documentation care plans and reports Undertake nurse prescribing and to promote safe medicine management within the team.Managerial To coordinate and prioritise the management of care for the individuals on the caseload to support the matron to manage sickness, absence, recruitment and retention of staff. Ensure that off duty rotas and e-rosters are planned appropriately to meet the needs of the service.

To support the matron to monitor, appraise and supervise the performance, conduct and practice of the team both directly and indirectly as appropriate; To influence colleagues to effect changes in service delivery to improve patient care within constraints of job role Create, maintain and enhance effective working relationships within the nursing team and other care providers across the alliance To investigate accidents and incidents; identify and implement corrective action plans and monitor completion of action plan. Share learning from incidents, complaints and support safeguarding compliance To develop and mentor students, colleagues. Facilitate good team working and process through positive leadership. Balance demands of workload whilst ensuring partnership and collaborative working with several agencies who operate different practice policies To provide cross-cover if required for rapid response and to deputise in the absence of the Complex care matron Professional Development Keep up to date on clinical and professional developments in line with re-validation Work with the practice educators and Specialist Nurses to provide clinical supervision and to develop training programmes as required.

Work with the Pre-registration Facilitator in planning and providing appropriate learning experiences for students. Participate in the Trusts learning sets and clinical supervision systems. Actively contribute to and participate in research and screening programmes where appropriate. Utilising research findings and evidence based practice review and analyse a range options to inform clinical decision making.

To participate in changes to service delivery To utilise knowledge of clinical governance and risk management to provide safe and effective services to patients with Long Term Conditions and End of Life Care. Service and practice development To support any managerial, professional practice and service developments are implemented effectively within the team. To actively participate in directorate clinical governance arrangements contributing to the development of risk assessment action plans. To participate in the recording of relevant information for monitoring contact activity, evaluating team activities and other data required.

To actively identify areas for service development, interpreting relevant policies, and work in partnership with others to lead and take these forward