Frailty Nurse

This role is centred on proactive and reactive care reviews, including advance care planning discussion, comprehensive geriatric assessments and, if appropriate, structured medication reviews.

The role aims to improve outcomes for frail patients, reduce avoidable hospital admissions, and support quality improvement across the network.

The role involves carrying out advance care planning discussions, comprehensive geriatric assessments and structured medication reviews (SMRs). These duties will be carried out in care homes, patients own homes or in the GP surgery.

You will:

• Conduct regular reviews for eligible patients, including patients in care homes and house bound patients
• Support QOF work relating to the patients
• Conduct In-practice frailty reviews for patients attending appointments
• Conduct remote consultation frailty reviews where appropriate

You will work closely with the Frailty & Care Home Lead GPs and be supported by a Multi-Disciplinary Team (MDT). The role includes attendance at MDT meetings, as appropriate.

Faversham Medical Group consists of 2 GP surgeries;

Faversham Medical Practice and Newton Place Surgery. We also run an Urgent Treatment Centre based at Faversham Health Centre.

We are a friendly and supportive team.

Faversham is a beautiful, historic market town. It is closeto the vibrant city of Canterbury; just 60 miles from London and yet within easy reach of attractive coastline areas and beaches.

1. Clinical Responsibilities

The post holder will:

• Ensure that all eligible residents in aligned care homes are identified and offered both seasonal and routine vaccinations
• Contribute to anticipatory care planning and personalised care discussions
• Provide remote consultations where clinically appropriate
• Deliver in-practice frailty reviews for patients attending appointments

2. Care Home & Frailty Service Delivery

• Build effective working relationships with care home and PCN staff
• Contribute to reducing avoidable admissions and improving continuity of care
• Participate in service development and refinement of frailty pathways

3. QOF & Quality Improvement

The Frailty Nurse will:

• Support QOF-related work for patients
• Contribute to chronic disease reviews and monitoring
• Ensure accurate clinical coding and documentation
• Participate in audit and quality improvement initiatives, where appropriate

4. Multidisciplinary Working

• Work collaboratively within a MDT
• Liaise closely with the GPs
• Attend MDT meetings, as appropriate
• Contribute to coordinated, team-based patient care

5. Professional Responsibilities

• Maintain active NMC registration
• Work within professional scope of practice and competencies
• Demonstrate safe, evidence-based clinical decision-making
• Engage in continuous professional development
• Maintain revalidation requirements
• Uphold confidentiality, safeguarding and data protection standards

• In the course of seeking treatment, patients entrust us with, or allow us to gather, sensitive information in relation to their health and other matters. They do so in confidence and have the right to expect that staff will respect their privacy and act appropriately
• In the performance of the duties outlined in this job description, the post-holder may have access to confidential information relating to patients and their carers, practice staff and other healthcare workers. They may also have access to information relating to the practice as a business organisation. All such information from any source is to be regarded as strictly confidential
• Information relating to patients, carers, colleagues, other healthcare workers or the business of the practice may only be divulged to authorised persons in accordance with the practice policies and procedures relating to…