Frailty Nurse

Dyddiad hysbysebu:	18 Rhagfyr 2025
Cyflog:	Heb ei nodi
Gwybodaeth ychwanegol am y cyflog:	Negotiable
Oriau:	Llawn Amser
Dyddiad cau:	16 Ionawr 2026
Lleoliad:	Cornwall, PL31 2JJ
Cwmni:	NHS Jobs
Math o swydd:	Parhaol
Cyfeirnod swydd:	A1380-25-0024

Crynodeb

Management & Leadership: To have an awareness of key MDT targets and priorities in terms of the operational/strategic plan for the system and related initiatives; to actively support the organisation in delivering high quality care and maintaining Care Quality Commission Compliance (CQC). To comply with relevant national guidelines, including NICE Guidance and National Standards Framework and within a scope of your own clinical standards. To contribute to the identification and development of relevant clinical protocols and strategies to enhance both the continuity and standard of specialist care whilst ensuring equity of access to the service, ensuring that all care is given in accordance with agreed protocols. To work with the MDT to develop, implement and evaluate integrated care pathways and systems of MDT documentation. Participate in policy development through professional forums and implement practice ensuring the clinical practice reflects national and local drivers Communication: Maintain and foster good relationships with all colleagues concerned with the provision or development of healthcare services. Forge effective links within Primary, secondary and community services to ensure effective communication through appropriate forums. Timely recording patient activities for IT data collection, dealing with e-mail queries, stock and equipment ordering. Preserve confidentiality and compliance to GDPR, Data Protection Act, Access to Health Records and Consent for Treatment. Demonstrate good communication skills to facilitate effective communication with patients and their carers, including sensitive and accurate information about their condition. Provide and receive complex, sensitive and confidential information and overcome potential barriers to communication, such as language, disability. Inform other professionals about changes in patients' condition. Act as a patient advocate as required ensuring individual needs, preferences and choices are delivered by the Service. Education & Training: Assume responsibility for own professional development and personal knowledge. Monitor own performance against agreed objectives through the process of IPR and personal development plans, Professional regulations and maintain professional expertise by arranging and attending meetings, study days and in service training for the team members. Facilitate and develop team members. Participate in Reflective Practice, Practice Supervision and Appraisals as per organisational) policies. Support student development and placement Plan and participate in the supervision, teaching and provision of community experience for all nurse learners and other personnel as appropriate. Develop the learning environment to promote lifelong learning and staff development. Identify areas of practice/role development and enable and support staff to initiate change. Work towards becoming an Independent Prescriber Care home support responsibilities, as required: (may include covering team absence or annual leave) Weekly check-in meetings with homes - which should include: facilitating and managing the delivery of the review (either remotely or in person, wherever appropriate), facilitated by an MDT where practically possible. Review patients identified by the care home as a clinical priority for assessment, review any new residents. Support the provision of care for those patients identified as a clinical priority; include appropriate and consistent medical oversight with liaison / input from a GP and/or geriatrician (with the frequency and form of that input determined by clinical judgement). Support homes with end of life care planning as required Support homes as appropriate with care planning establishing a process to: Support development of personalised and individually agreed treatment escalation plans for care home residents with care home teams, including end of life care plans. The role should work towards implementing the Comprehensive Geriatric Assessment. Facilitate the timely appropriate use of medication reviews, working with the Pharmacy Technician, including: medication supply , including end of life medication. Arranging the delivering structured medication reviews - via video or telephone consultation where appropriate - to care home or housebound residents. Supporting reviews of new residents or those recently discharged from hospital to patients home or care home beds To support older patients and patients with moderate and severe frailty in their own homes by: Identification of patients using an agreed case finding tool (Electronic Frailty Index [eFI] or Rookwood score) who require completion of a Comprehensive Geriatric Assessment (CGA). Patients should be considered for MDT/caseload management following assessment. Participating in annual reviews for housebound patients with long-term chronic conditions. Signposting to other services/voluntary sector as appropriate and to consider social prescribing, (for example, in support of alleviating loneliness brought on by social isolation) Organisation and attendance at Primary Care Network (Bosvena) Multi-Disciplinary Team (MDT) meetings