Frailty Nurse

Aspen Medical Practice is looking for an experienced, motivated and compassionate Frailty Nurse to join our established and friendly multidisciplinary Frailty Team.

This is an exciting opportunity to play a key role in supporting the delivery of proactive, high-quality care for our frail and elderly patients. The role is central to improving outcomes for patients living with frailty through early identification, personalised care planning and coordinated working across primary, community and secondary care services.

The successful candidate will work as part of a supportive multidisciplinary team, delivering structured frailty reviews in line with current contractual requirements. A significant part of the role will involve home visits and the management of complex patients in the community.

In this job role, you will assess individual patient needs, initiate investigations, and initiate appropriate holistic, evidence-based treatment and care and liaise with other teams as appropriate.

Aspen Medical Practice was formed from the merger of four practices in 2018 and is now a single large practice looking after about 32000 patients. We have 140 employees who all work together as one multi-disciplinary team trying to provide the best service we can for our patients and their families.

Whilst patient care is key, we also value the wellbeing of our employees and offer free parking, access to the NHS pension scheme, enhanced sickness allowances, monthly protected learning time events, length of service recognition and much more. We listen to our staff via suggestion boxes, surveys and our staff forum and have made several changes in recent years in response to this.

Role and Objectives

The frailty nurse will work within their professional scope of practice in a general practice environment as part of our Primary Care Network. As a key member of the Aspen PCN frailty team, they will play a key role in preventing avoidable hospital admissions and helping patients age well and better manage their conditions. They will offer post discharge reviews and proactive care.

This role focuses on identifying, assessing and managing patients living with moderate to severe frailty, with the aim of improving patient outcomes, reducing avoidable admissions, and supporting patients to remain safely at home.

In this fast-paced and rewarding role, they will be expected with sound clinical judgment within the boundaries of their professional practice.

Working under the guidance of the Frailty Lead GP and Frailty Matron, the Frailty Nurse will receive daily support from Frailty Care Coordinators, Clinical Pharmacists, wellbeing practitioners, social prescribers and the wider PCN.

Key Tasks and Responsibilities

• 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.
• Promote/ support health & wellbeing, helping patients to remain independent and well at home.
• Facilitate patient education, self-management of disease, and behaviour modification.
• Conduct thorough person-centred needs assessment to develop care plans for each patient.
• Represent individuals and families interests when they cannot 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 and seek clinical advice as appropriate.
• Accurately update patient records on Systm One.
• All documentation must be timely, relevant, and clearly reflect the care provided, using Systm One.
• 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 facilitate good working relationships.
• Attend 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 as required.
• Participate in team meetings, audits, and data collection for improving patient care.
• Support HCAs, Care Coordinators in delivering high-quality care to frail and…