Practice Nurse - Frailty

Job Description

Job Title:

Frailty Nurse

Hours:

2 days per week

Location:

Brynteg Surgery, Ammanford, covering both practice sites and patient homes

Job Purpose:

To deliver a proactive, structured frailty service within the practice, focusing on the identification, assessment and ongoing management of patients living with moderate to severe frailty.

The post holder will work autonomously to manage a defined cohort of patients, with the aim of improving patient outcomes, reducing avoidable hospital admissions, and supporting patients to remain safely within the community.

• Undertake comprehensive frailty assessments, including home visits where appropriate
• Identify patients suitable for the frailty service and prioritise workload based on clinical need
• Develop, implement and review personalised care plans
• Complete initial and follow up frailty reviews in line with service requirements
• Assess and manage clinical risk including falls, polypharmacy concerns and safeguarding
• Escalate complex or high risk cases appropriately to GPs or wider MDT

• Work collaboratively with GPs, pharmacists, district nurses, community teams and secondary care services
• Act as a key point of contact for patients within the frailty cohort
• Support proactive case management of high risk and vulnerable patients
• Liaise with carers and family members where appropriate

• Contribute to the development and ongoing improvement of the practice frailty service
• Support delivery of contractual requirements relating to frailty care
• Ensure activity is appropriately coded and recorded to support service monitoring and claims

• Maintain accurate, contemporaneous and high quality clinical records using EMIS
• Ensure all patient interactions and care plans are clearly documented
• Contribute to audits, reporting and service evaluation as required

• Work within NMC Code of Conduct and maintain professional registration
• Maintain up to date clinical knowledge relevant to frailty and long term condition management
• Participate in relevant training and continuing professional development
• Adhere to practice policies including safeguarding, infection control, and information governance

Work flexibly across both practice sites

• Undertake home visits as a routine part of the role
• Support the wider team as required in delivering safe and effective patient care

The post holder will be accountable to the Practice Manager and GP Partners.

Contract Type:
This post is initially offered on a fixed term basis linked to current service funding, with the potential for extension subject to ongoing service need and funding.