Job Description
Job Title: Frailty Nurse
Hours: 2 days per week
Location: Brynteg Surgery, Ammanford, covering both practice sites and patient homes
Job Purpose: To deliver a proactive, structured frailty service within the practice, focusing on the identification, assessment and ongoing management of patients living with moderate to severe frailty.
The post holder will work autonomously to manage a defined cohort of patients, with the aim of improving patient outcomes, reducing avoidable hospital admissions, and supporting patients to remain safely within the community.
Key Duties and Responsibilities
* Undertake comprehensive frailty assessments, including home visits where appropriate
* Identify patients suitable for the frailty service and prioritise workload based on clinical need
* Develop, implement and review personalised care plans
* Complete initial and follow up frailty reviews in line with service requirements
* Assess and manage clinical risk including falls, polypharmacy concerns and safeguarding
* Escalate complex or high risk cases appropriately to GPs or wider MDT
Care Coordination
* Work collaboratively with GPs, pharmacists, district nurses, community teams and secondary care services
* Act as a key point of contact for patients within the frailty cohort
* Support proactive case management of high risk and vulnerable patients
* Liaise with carers and family members where appropriate
Service Delivery
* Contribute to the development and ongoing improvement of the practice frailty service
* Support delivery of contractual requirements relating to frailty care
* Ensure activity is appropriately coded and recorded to support service monitoring and claims
Administration and Record Keeping
* Maintain accurate, contemporaneous and high quality clinical records using EMIS
* Ensure all patient interactions and care plans are clearly documented
* Contribute to audits, reporting and service evaluation as required
Professional Responsibilities
* Work within NMC Code of Conduct and maintain professional registration
* Maintain up to date clinical knowledge relevant to frailty and long term condition management
* Participate in relevant training and continuing professional development
* Adhere to practice policies including safeguarding, infection control, and information governance
General Work
Work flexibly across both practice sites
* Undertake home visits as a routine part of the role
* Support the wider team as required in delivering safe and effective patient care
Accountability
The post holder will be accountable to the Practice Manager and GP Partners.
Additional Information
Contract Type: This post is initially offered on a fixed term basis linked to current service funding, with the potential for extension subject to ongoing service need and funding.
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