Housebound Patients: At integral member of the WECS team comprising GP(s), Nurse Practitioner, Nurse, HCA, OT, paramedic, ACPs, Physiotherapist, Frailty healthcare assistants Home visits to identified patients to complete therapy assessments which may include baseline assessments using an agreed proforma CGA template to include (but not exclusively) continence, skin, nutritional status, care needs and unmet needs. Lone working policy to be followed. Develop specialist care and/or rehabilitation programme, to promote and sustain independence/ wellbeing for the individual or carer in the relevant setting, which will usually be a residential setting. To contribute towards the development of Therapy within The Frailty Team. Monitor standards of practice. Referral of patients when appropriate to Frailty Health Care Assistants to collect additional information or to complete additional assessments e.g. weight monitoring, BP checks, ECG, phlebotomy etc Follow up visits to patients following a new assessment or after a re-referral until identified problems are addressed Make referrals to the wider MDT (including third sector) if and when appropriate Develop and communicate therapy management plans working in the integrated neighbourhood team Ensure patients who are discharged from the service are aware they can re-refer if deteriorating, and how they can re-refer Manage own caseload of patients determine appropriate frequency for review, schedule appointments Support with comprehensive data collection Contribute to a Personalised Care and Support Plan using the Dorset Care Plan Awareness and understanding of the supporting document Housebound visiting model specification Ageing Well Clinic Deliver the requested components of an assessment in an outpatient / community setting This assessment will form part of a CGA Patient goals are an essential component of the review, using the principles of personalised care and support planning Awareness and understanding of the supporting document Ageing Well Clinic Specification With a focus on falls, mobility, transfers Encouraging independence and activity For all patients Contribution towards the Dorset Care Plan (The Personalised Care and Support Plan of choice in Weymouth and Portland) Utilise clinical skills e.g. venepuncture, manual BP, weight when appropriate Development towards - Advance Care Planning discussion to include discussion about resuscitation status (training and experience dependent) Other Attendance at surgery MDT meetings or EHCH MDT meetings if requested to do so Comprehensive record keeping on SystmOne, using bespoke templates Ensure work emails are regularly accessed Ensure work mobile is carried at all times and that messages are picked up at regular intervals through the working day Interpret data from various sources e.g. frailty data, MDT data, frailty registers to determine which patients would benefit from holistic review if requested to do so Manage workload effectively and ensure that sufficiently detailed contemporaneous notes are kept at all times.