Due to the success of our Frailty Service, an exciting expansion and development opportunity has arisen. We are looking to recruit an enthusiastic and motivated Frailty Practitioner to join our dynamic team of dedicated Nursing and Medical Staff working in the Urgent Community Response (for patients 18yrs +), Ambulatory and Community Frailty and Frailty Virtual Ward. The post holder will provide expert direct patient care, screen and identify the frail older patient in their own homes, in 24 hour care and in the acute trust. The successful candidates will help to improve pathways for patients who are experiencing an acute crisis and decompensating frailty in the community. You will be responsible for delivering and supporting high quality care, act as an expert practitioner and a role model, offering a patient centred holistic approach to care planning and maximizing independence and well‑being of those living with frailty.
RESPONSIBILITIES
- Plan and manage complete episodes of care, working in partnership with others, and delegating and referring as appropriate to optimize health outcomes and resource use, as well as providing direct support to patients and clients.
- Develop and use knowledge and skills in order that professional development can be maintained and keep professional portfolio up to date.
- Practice autonomously and be self-directed.
- Use professional judgment in managing complex and unpredictable care events and capture the learning from these experiences to improve patient care and service delivery.
- Draw upon an appropriate range of multi‑agency and inter‑professional resources in their practice.
- Appropriately define the boundaries of own practice, asking advice from consultant nurse or medical lead when unsure.
- To ensure that services are delivered effectively and efficiently against predetermined clinical performance targets.
- Have a proactive approach to promoting health and wellbeing, detection and prevention of vulnerability, preventing illness, reacting and responding to existing or potential ill health issues and contributing to reduction in length of stay or reducing unplanned hospital admissions.
- Conduct yourself and practice within an ethical framework based upon respect for the well‑being and safety of patients and clients for the clinical case management of a defined population.
- The post‑holder will collaborate with a wide range of statutory and voluntary organisations to maximise the nursing contribution in health improvement, planning and delivery of care to individuals, families, and communities.
- Actively seek and participate in peer review of own practice.
- Enable patients/clients to learn by designing and coordinating the implementation of plans appropriate to their preferred approach to learning, motivation and developmental stage In partnership with Consultant Staff, Consultant Nurse, Allied Health Professionals, and Head of Quality, develop robust governance systems by contributing to the development and implementation of evidence‑based protocols, documentation processes, standards, policies and clinical guidelines through interpreting and synthesising information from a variety of sources and promoting own practice.
- Work in collaboration with others to plan and deliver interventions to meet the learning and development needs of own and other professions.
- Advocate and contribute to the development of an organisational culture that supports continuous learning and development, evidence‑based practice, and succession planning; and have high‑level communication skills and contribute to the wider development of those working in their area of practice by publicising and disseminating their work through presentations at conferences and articles in the professional press.
- Develop effective partnerships and positive working relationships with a variety of internal and external agencies to support seamless care provision across all agencies.
CLINICAL & PROFESSIONAL RESPONSIBILITIES
- Maintain Professional Registration.
- Adhere to relevant Code of Practice of Professional body.
- Assess individuals, families and populations holistically using a range of different assessment methods, such as physical examination, ordering and interpreting diagnostic tests or advanced health needs assessment.
- Have a health promotion and prevention orientation and comprehensively assess patients for risk factors and early signs of illness.
- Be able to draw on a diverse range of knowledge in decision‑making to determine evidence‑based therapeutic interventions (which will include prescribing, planning treatments, reviewing medication, and actively monitoring the effectiveness of any interventions).
- Prescribe and review medication for therapeutic effectiveness, appropriate to patient needs and in accordance with evidence‑based practice and national and Trust protocols and formularies.
- Work with patients and their carers to support compliance with and adherence to prescribed treatments.
- Provide information and advice on prescribed or over‑the‑counter medication on medication regimens, side‑effects, and interactions.
- In the absence of consultant, lead the co‑ordination of care, working with partner agencies and key stake holders to ensure effectiveness of outcomes for defined case mix of patients.
- Provide strategic clinical leadership in relation to area of specialty, working as an autonomous practitioner.
- Lead the co‑ordination of the care for people on a defined caseload, demonstrating advance competence in highly complex decision making, assessment and the management of clinical needs within specialist area of practice and refer to specialist services as appropriate.
- Provide clinical leadership in workforce planning and skills profiling targeting resources to meet the needs of individuals, families, and communities.
- Undertake age appropriate physical and psychosocial assessment, interpreting core clinical and diagnostic findings to determine a diagnosis and develop an evidence‑based plan of care.
- Instigate therapeutic interventions and treatments aimed at improving health outcomes and promoting self‑care, evaluate the effectiveness of interventions, modifying plans for optimal outcomes. Referring to Medical / Nurse Consultant where needed.
- Develop a knowledge of disease processes and consequences and provides specialist clinical advice to colleagues, individuals, families, and communities.
- Provide high level anticipatory care through the early identification of disease exacerbation to reduce the likelihood of acute illness, risks and prevent hospital admission.
- Actively initiate and lead medicine management practice, review prescription, planning and adjustment of medicines, facilitating patients understanding to improve concordance with the support of their families.
- Lead the development, maintenance and monitoring of service standards ensuring clinical and non‑clinical practice interventions are based on the most recent evidence available and findings are incorporated into nursing practice.
- Demonstrate advanced clinical and non‑clinical interventions and act as an advisor and educator to colleagues and a variety of learners in area of specialty. Always working within scope of practice.
- Supervise and teach learners in collaboration with education providers and other key stakeholders.
- Ensure expert knowledge, skills and competency are updated and maintained through appropriate CPD, training and development opportunities to enable effective care to be delivered in line with current research‑based evidence and practice.
- Ability to work autonomously, asking for help and advice when necessary.
- Ability to interact effectively with people who have different levels of communication skills.
ADMINISTRATIVE RESPONSIBILITIES
- To ensure that the recording of patient care is comprehensive, concise and in line with the NMC Record Keeping guidance.
- Ensure IT systems are current e.g., ADT to ensure that all patient information is confidential and is not disclosed to a third party except with permission of the patient or the Manager in Charge.
- To keep patient records up to date on a day‑to‑day basis following any interaction with patients/relatives.
TEACHING & TRAINING RESPONSIBILITIES
- Improve quality and develop practice of clinical teams by sharing skills and knowledge both formally and informally.
- Be proactively involved in developing strategies and undertaking activities that monitor and improve the quality of healthcare and the effectiveness of their own and others' practice.
- Strive constantly to improve practice and health outcomes so that they are consistent with or better than national and international standards through initiating, facilitating and leading change at individual, team, organisational and system levels.
- Continually evaluate and audit the practice of self and others at individual and systems levels, selecting and applying valid and reliable approaches and methods which are appropriate to needs and context, and acting on the findings.
- Critically appraise and synthesize the outcomes of relevant research, evaluations and audits and apply the information when seeking to improve practice.
DISABILITY CONFIDENT
Disability Confident is a programme that encourages employers to offer interview opportunities to applicants who declare a disability and meet the role's required criteria. When high‑volume recruitment periods occur, the employer may limit the proportion of interviewed candidates to ensure a balanced process. Under our scheme, we support applicants who meet the minimum requirements while maintaining a fair selection approach.
ACHIEVEMENTS
- Rated Outstanding by CQC Inspection August 2018
- Top 100 places to work in the NHS (NHS Employers & Health Service Journal)
- National Preceptorship Accreditation 2023 for Nursing & AHP Preceptorship Programme
