Frailty Nurse

We are looking for an experienced Nurse with a background in frailty to join our innovative Ageing Well Team across the PCN. The post holder will provide proactive,person-centered care for people living with moderate and severe frailty,including undertaking and coordinating Comprehensive Geriatric Assessments(CGA) to identify medical, functional, psychological and social needs and agreeindividualised care plans.

This is an exciting opportunity for an enthusiastic, motivated Registered Nurse, working closely with our O/T, physio & care coordinators to provide proactive carefor the moderately and severely frail. This role is integral to the assessment and management of patients living with frailty to allow the best access to careand support. You will be an autonomous practitioner who is adaptable, has aflexible can-do attitude with a passion for excellence & ability to workwell both on their own & as part of a team.

This is acommunity-based role applicants must have a full driving license & accessto a vehicle daily.

The successful candidate should be an experienced practitioner who willwork in partnership with other health professionals in supporting frailpatients and providing holistic patient care. They will act within their professional boundaries and competencies, assessing, planning, implementing and evaluating patient care.

They will participate inMDT meetings to discuss patients that the Ageing Well Team are supporting. Asa result, they must have high level communication/interpersonal skills to negotiate & establish collaborative partnerships with patients & care professionals and have enthusiasm &the ability to use their own initiative.

Employed by Selby Prime Care Ltd but subcontracted to Selby Town PCN,this is a role to support patients across Selby Town PCN.

The PCNworks over four practice sites (Beech Tree Surgery, Escrick Surgery,Posterngate Surgery and Scott Road Medical Centre) a local voluntary sectorsite & our local community hospital.

The PCNhas a Clinical Director, two Clinical Lead GPs and is managed by the PCNO

perations Manager & Business Manager. We work in increasinglycollaborative partnerships across several work streams, which include importantpriority areas of mental health, frailty, urgent care and health inequalities.

Our team consists of a diverse multi-professional workforce which includespharmacists, MSK practitioners, mental health workers, care coordinators,social prescribing link workers, a frailty therapy team, an urgent care coordinator, UCPs, paramedics, ACPs, a transformational lead, a digital lead,health & wellbeing coach.

KEYRESPONSIBILTIES

To visit clients who meet the Frailty assessmentcriteria within their usual place of residence.

To assess and identify the health needs of patients who are frail and who may have long-term conditions.

To undertake and coordinate Comprehensive Geriatric Assessments (CGA), within professional competence, covering physical health, medicines, cognition, mood, mobility, falls risk, nutrition,continence, functional ability, social circumstances and future care wishes.

To use CGA findings to develop, document andreview person-centered, strengths-based care and support plans with patients,carers and the multidisciplinary team, escalating clinical concerns appropriately.

To provide clinical leadership, guidance and support to care coordinators, including advice on patient care, risk management, escalation and effective multidisciplinary working within agreedprofessional boundaries.

To assess, plan, implement and evaluateprogrammes of care to address the identified needs of patients identified asbeing frail and/or those with long-term conditions.

To support the development of patientsindividual Personalised Care and Support Plans.

Develop disease specific patient information and education to support patients self care.

Participate in education &staff development, including specialised CPD relevant to Frailty and Dementia and actively participate in regular supervision.

Please see attached job description for full details of the role.

• Please see attached job description and person specification for full details.

• Registered Nurse with Nursing and Midwifery Council.
• Evidence of meeting PREP Requirements
• Experience of mentoring/supporting learners or ability to demonstrate the skills required for effective mentoring
• N/A

• Demonstrable nursing experience across a variety of settings
• Experience of delivering…