Frailty Nurse

Job summary

Armley Primary Care Network (PCN) are recruiting to a new position of PCN Frailty Nurse to enhance our established Frailty Team. We are looking for an experienced, caring, dedicated, reliable and patient focused individual who enjoys meeting new people.

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.

**When applying please include a covering letter alongside your CV explaining how you are suited to this role and confirm you meet the essential requirements.**

Main duties of the job

As a key member of the PCN Frailty Team, the Frailty Nurse will:

Work closely with GPs and independently to deliver safe and effective care to the frail population and patients living in care homes.

Build and keep updated a robust register of frail patients and use clinical frailty scoring systems to regularly measure frailty.

Support and improve the health and wellbeing of frail, housebound patients

Liaise effectively with other health care practitioners and initiate referrals as appropriate.

Use a person-centred approach to undertake a comprehensive needs assessment.

Provide expert professional advice to patients, carers and colleagues and ensure the maintenance of clinical excellence.

Develop new and innovative concepts, models, methods, and practices to deliver new and improved primary care services to meet the needs of the frail population.

Support Health Care Assistants/Care Coordinators in delivering service to Frail/housebound patients

Organise and chair Multi-disciplinary team meetings, and develop and maintain effective working relationships with health and social care colleagues and other agencies to ensure that frail and complex patients and those with long term conditions receive a consistent, integrated response to all contacts/referrals.

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 36,000 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.

The successful applicant will work alongside practice teams on a day to day basis, and will benefit from being networked with the wider Frailty team within our PCN.

Job description

Job responsibilities

Job Role Summary

As a member of the Armley Primary Care Network (PCN) FrailtyTeam, the Frailty Nurse will:

Work closely with GPs and independently todeliver safe and effective care to the frail population and patients living incare homes.

Build and keep updated a robust register offrail patients and use clinical frailty scoring systems to regularly measurefrailty.

Support and improve the health and wellbeing offrail, housebound patients

Liaise effectively with other health carepractitioners and initiate referrals as appropriate.

Use a person-centred approach to undertake acomprehensive needs assessment.

Provide expert professional advice to patients,carers and colleagues and ensure the maintenance of clinical excellence.

Develop new and innovative concepts, models,methods, and practices to deliver new and improved primary care services tomeet the needs of the frail population.

Support Health Care Assistants/Care Coordinatorsin delivering service to Frail/housebound patients

Organise and chair Multi-disciplinary teammeetings, and develop and maintain effective working relationships with healthand social care colleagues and other agencies to ensure that frail and complexpatients and those with long term conditions receive a consistent, integratedresponse to all contacts/referrals.

Working strictly in accordance with specific guidelines andagreed protocols, the Frailty Nurse will assist with the ongoing support ofpatients, families and carers in a professional manner - using resourceseconomically and efficiently.

In line with PCN policy, the Frailty Nurse will updatepatient records using both EMIS and SystmOne, ensuring entries are accurate,relevant, and timely and that they appropriately communicate the care provided.

Duties will be undertaken in an autonomous manner withadvice from the practice care teams and GPs as appropriate.

The Frailty Nurse will understand and follow procedures andpolicies on information governance, with strict adherence to protocolsregarding the sharing of personal and confidential information betweendifferent organisations/individuals. Appropriate competency-based training andall mandatory training will need to be completed.

Main JobResponsibilitiesClinical Nursing Practice

Undertake clinical nursing practice usingexpert knowledge and clinical skills to deliver holistic care to patientsliving in their own home or care home.

Proactively manage long term conditions.

Directly admit patients to secondary carehospital in acute medical need.

Refer patients to other medicalspecialities for assessment if deemed appropriate.

Refer patients as appropriate to othermembers of the multidisciplinary team, secondary care and to other statutoryand voluntary organisations.

Work within professional guidelines andcodes of conduct.

Work within all relevant PCN practicepolicies and procedural guidelines , infection control, chaperoning, riskmanagement.

Communicate with patients, relatives, andcarers to undertake Advanced Care Plan/ReSPECT forms.

Initiate the process of diagnosis withpatients suspected to have a chronic disease , diabetes, COPD, asthma, IHDreferring to other clinical staff as appropriate.

Contribute to PCN practice targets bothlocal and national within the disease management agents , QOF, prescribingincentive scheme.

Contribute to disease registers.

Undertake annual review of patientsunderstanding and ability to self-manage and medication reviews.

Refer to other members of the extendedprimary health care team as appropriate , chiropodist, dietician,specialist nurses.

Actively implement safeguarding protocolsfor children and vulnerable adults and to know who to refer to and how toescalate concerns about radicalisation.

Strategic Development of Primary Care Services

Contribute to the strategic development ofprimary care and public health services to meet patient and population needswithin the practice and across the wider organisation particularly with theFrail and Care Home Contracts and Initiatives. Keep up to date with schemes andcontractual agreements by liaising with Practice Managers, GPs and IntegratedCare Board.

Work/liaise across multi-professional and agencyboundaries.

Work at the forefront of practice innovation.Determine how to deal with ambiguous or unique problems to develop and advanceprimary care services for the benefit of patients, carers and communities.

Health Improvement

Share innovation and new learning with others.

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

Make referrals to statutory and voluntaryagencies as appropriate.

Communication

Regularlycommunicate service-related information to the broad spectrum of staff withinthe PCN and its practices.

Buildand communicate therapeutic working relationships with a wide array ofstatutory and voluntary organisations for the benefit of patient care andfacilitates good working relationships.

Manage/Lead Self/Others

Develop and lead on evidence-based practice.

Promote effective communication andrelationships within the team.

Actively participate in clinical, PCN andpractice meetings.

Develop own knowledge and practice to meetobjectives/changes in service, through attendance on study days, self-directedlearning, and reflection on practice.

Integrate theory into practice and establishformal links with educational institutions.

Act as mentor for Health Care Assistants, CareCo-ordinators and other staff within the PCN practices.

Promote best practice.

Influence and develop policy

Implement and adhere to local/national, clinicalcommissioning group and practice policies, propose developments andimprovements to service delivery.

Manage and use information

Make effective use of the clinical system byensuring the consistent and accurate entering of data and use of read codes.

Facilitate the use of up-to-date informationtechnology to collate accurately and timely information as and when required bythe practice.

Confidentiality

Ensure everything confidential is locked away atthe end of the day.

Ensure that confidentiality is adhered to interms of patient information and the protection of personal and sensitive data.

Health and Safety

Identifying the risks involved in workactivities and undertaking such activities in a way that manages those risks.

Making effective use of training to updateknowledge and skills.

Actively reporting of health and safety hazardsand infection hazards immediately when recognised.

Keeping own work areas and patient areasgenerally clean, assisting in the maintenance of general standards ofcleanliness consistent with the scope of the job holders role.

Reporting potential risks identified.

Demonstrate due regard for safeguarding andpromoting welfare of children.

Equality and Diversity

Acts in a way that recognises the importance ofpeoples rights, interpreting them in a way that is consistent with PCN practiceprocedures and policies, and current legislation.

Respects the privacy, dignity, needs and beliefsof patients, carers, and colleagues.

Safeguarding

Be familiar with and adhere to the PCN practicesafeguarding policies, procedures and guidelines for both children and adultsat risk of abuse or neglect. This mustbe in conjunction with the Multi-agency Safeguarding Children and SafeguardingAdults at risk of abuse and/or neglect policy, protocols, and guidelines.

Knowledge, Training and Experience:

registered nurse with at least two years recentprimary or community nursing experience

experienced and up to date in : blood pressure,temperature, pulse, testing blood sugars, O2 sats, tissue/skin health, diabeticfoot 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

Other:

Maintain the highest standards of conduct and integritywithin organisation adhering to relevant Codes of Conduct and the NHSConstitution

Be aware of andadhere to the provisions of the Health and Safety at Work Act and ensure ownsafety and the safety of colleagues and patients

Participate in our appraisal system, matching organisationalaims with individual objectives

Comply with all organisational and statutory requirements

Undertake all mandatory training required for the role

Be aware of individual responsibilities under the Equal Opportunities andDiversity in Employment Policy and adhere to the provisions of the policy

Work flexibly as required by the PCN, including working at different GPPractices or community locations in the local area.

Key Working Relationships

Frailty Team

Social Prescribing team

Clinical Pharmacists

PCN Manager

PCN Clinical Director

PCN Frailty Clinical Leads

GPs, Practice Managers, nurses and otherpractice staff

Members of the public

Members of local communities

Providers of care including acute Trusts,independent sector and providers, community services, community mental healthservices

Local Care Partnerships Linked to the PCN

Person Specification

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 multiprofessional 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

Personal Qualities

Essential

-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 identify risk and assess / manage risk when working with individuals -Have a strong awareness and understanding of when it is appropriate or necessary to refer people back to other health professionals/agencies, when what the person needs is beyond the scope of the Frailty Nurse role -Ability to maintain effective working relationships and to promote collaborative practice with all colleagues -Ability to demonstrate personal accountability, emotional resilience and 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 -Ability to provide motivational coaching to support peoples behaviour change -Knowledge of, and ability to work to policies and procedures, including confidentiality, safeguarding, lone working, information governance, and health and safety -Demonstrable commitment to professional and personal development - Proficient in MS Office and web-based services

Other Requirements

Essential

- Meets a

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