PCN Frailty Nurse

Dyddiad hysbysebu:	10 Gorffennaf 2025
Cyflog:	Heb ei nodi
Gwybodaeth ychwanegol am y cyflog:	Negotiable
Oriau:	Llawn Amser
Dyddiad cau:	25 Gorffennaf 2025
Lleoliad:	Leeds, LS12 1HU
Cwmni:	NHS Jobs
Math o swydd:	Parhaol
Cyfeirnod swydd:	W0023-25-0000

Crynodeb

Main Job Responsibilities As an integral member of the PCN Frailty Team, the Frailty Nurse will: 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, including those residing in care homes. Promote / support health & wellbeing, helping patients to remain independent and well at home. Facilitate patient education, self-management of disease, and behaviour modification. Undertake annual review of patients understanding and ability to self-manage Conduct thorough person-centred needs assessment to develop care plans for each patient. Represent individuals and families interests when they are not able to 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. Accurately update patient records on both EMIS and SystmOne systems. All documentation must be timely, relevant, and clearly reflect the care provided. 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 facilitates good working relationships. Organise and chair 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. Participate in team meetings, audits, and data collection for improving patient care. Support HCAs / Care Coordinators in delivering high-quality care to frail and housebound patients. Provide expert clinical advice and support to patients, carers, and colleagues, maintaining high standards of professional practice and clinical excellence. Operate in line with clinical protocols and guidelines, ensuring professional, compassionate support for patients, families, and carers - using resources responsibly and efficiently. Contribute to service development by creating and implementing innovative models, methods, and practices to enhance primary care services for the frail population. Regularly communicate service-related information to the broad spectrum of staff within the PCN and its practices. Ensure compliance with practice CQC requirements and maintain accurate documentation. Work within all relevant PCN practice policies and procedural guidelines e.g., infection control, chaperoning, risk management. Contribute to PCN practice targets both local and national Contribute to disease registers. Keep up to date with schemes and contractual agreements by liaising with Practice Managers, GPs and Integrated Care Board. Develop own knowledge and practice to meet objectives/changes in service, through attendance on study days, self-directed learning, and reflection on practice. Undertake all mandatory training required for the role Participate in our appraisal system, matching organisational aims with individual objectives Maintain the highest standards of conduct and integrity Knowledge, Training and Experience: registered nurse with at least two years recent primary or community nursing experience experienced and up to date in blood pressure, temperature, pulse, testing blood sugars, O2 sats, tissue/skin health, diabetic foot 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 Confidentiality Ensure that confidentiality is adhered to in terms of patient information and the protection of personal and sensitive data. Health and Safety Identify risks involved in work activities and undertake activities in a way that manages risks. Actively report health and safety hazards and infection hazards immediately when recognised. Maintenance of general standards of cleanliness consistent with the scope of the role. Equality and Diversity Act in a way that recognises the importance of peoples rights, interpreting them in a way that is consistent with PCN practice procedures and policies, and current legislation. Safeguarding Be familiar with and adhere to PCN practice safeguarding policies, procedures and guidelines for both children and adults at risk of abuse or neglect in conjunction with Multi-agency Safeguarding Children and Safeguarding Adults at risk of abuse and/or neglect policy, protocols, and guidelines. Key Working Relationships PCN Clinical Director Frailty Team PCN Frailty Clinical Leads GPs, Practice Managers, nurses and other practice staff PCN teams: Clinical Pharmacists, Social Prescribers, Dietician, Health and Wellbeing Coaches, Providers of care including acute trusts, independent sector and providers, neighbourhood teams, community services, geriatricians, community matrons, community mental health services Local Care Partnerships linked to the PCN