An exciting opportunity has arisen to join our expanding FrailtyTeam.We are growing our service to enhance the care we provide to our localcommunity, and were looking for a dedicated professional to become part of this forward-thinking team.
Our established Frailty Team currently includes a Community Frailty Practitioner, a Community Frailty Paramedic, and a Care Coordinator. ANon-Medical Prescribing qualification is essential for this role, and applicants must have successfully completed this qualification.
The PCN Frailty Team plays a key role in supporting our practices by conducting weekly ward rounds, monitoring new care home residents, and providing high-quality long-term condition management.
In addition, the team delivers a non-urgent housebound service, offering vital support for patients who are unable to attend the surgery but require ongoing management of their long-term conditions.
This is a fantastic chance to be part of a dynamic, compassionate team dedicated to improving frailty care across our community.
Main duties of the job
Applicants should be experienced clinical practitioners who, acting within their professional boundaries, will provide care for housebound and carehome patients including initial history taking, clinical assessment, diagnosis, treatment, and evaluation of care.
Lead long-time condition management focusing on elderly, frail, and housebound patients, including those in care homes.
They will demonstrate safe clinical decision-making and expert care, including assessment and diagnostic skills, for housebound and care home patients within the general practice setting.
The post holder will demonstrate critical thinking in the clinical decision-making process, with the ability to prioritise and triage the needs of the patients, accordingly, instigating appropriate investigations or referrals to colleagues and other care providers.
They will work collaboratively as part of the general practice multidisciplinary team to meet the needs of patients. The role is both varied and diverse with clinical support and mentorship provided to allow the successful candidate to flourish. The workload will consist of a mixture of home visits, care home visits and telephone consultations.
About us
Severnvale PCN (Primary Care Network) comprises four GP practices in South Gloucestershire delivering services to a population of circa 34,000 patients which includes 10 care homes. We are an enthusiastic, dynamic, and friendly PCN who constantly strive to improve patient pathways and health care outcomes.
The PCN team includes a Clinical Director, a PCN Manager, 2 Community Frailty Practitioner, a Care Co-ordinator, 4 Clinical Pharmacists, a Pharmacy Technician, 7 Care Coordinator Prescription Clerks, 2 dedicated Social Prescribing Link Workers and First Contact Physiotherapists.
Job responsibilities
Job responsibilities,
To work as part of a multi-disciplinary team across the PCN to care for our housebound and care home patients, including proactive assessment, diagnosis and treatment of individuals using a holistic approach. To undertake care home weekly ward rounds.
To assess, diagnose, investigate, treat, refer or signpost patients/service users within the community with undifferentiated or un-diagnosed condition relating to minor illness, minor injury or urgent problems.
The post holder will use advanced clinical skills to provide education to service users, promoting self-care and empowering them to make informed choices about their treatment.
The post holder must have access to a vehicle for home visits with mileage expenses remunerated by submission of a monthly mileage form. (Please note it is the post holder's responsibility to ensure that their car insurance is covered for business use).
* Visiting patients who are frail/have co morbidity in their homes or in a care home. Undertake care home ward rounds with the support of the PCNs Community Frailty Practitioner, Community Frailty Paramedic and Care Coordinator
* Prescribe/issue medications as appropriate following policy, patient group directives and local pathways. Independent Prescriber qualifications is essential.
* Maybe required to help with the Avoiding Unplanned Admission reviews
* Consult with patients, take medical histories, perform physical examinations, analyse, diagnose and explain medical problems during consultations and home visits.
* Recommend and explain appropriate diagnostic tests and treatment.
* Formulate differential diagnoses and develop and deliver appropriate treatment and management plans. Request and interpret results of laboratory investigations when necessary.
* Advanced end of life care planning to include ReSPECT discussions and development of Personalised Care and Support Plans.
* Advise patients on general health care and minor ailments, with referral to other members of the primary and secondary health care team as necessary.
* Undertake assessment for patients within their place of residence using diagnostic skills, initiation of investigations and feeding back to the patients GP where appropriate.
* To help manage/support patients with their long term condition.
* Support quality improvement and assurance initiatives within the PCN.
* Promote public health and screening programs, including immunisations and cervical screening.
* Integrate population health management approaches to reduce health inequalities.
* Work collaboratively with the wider practice team to enhance patient care.
* Work with local and national evidenced based policies and procedures.
* To communicate at all levels within the team ensuring an effective service is delivered.
* Ensure evidence-based care is delivered at the highest standards ensuring delivery of high-quality patient care.
Person Specification
Experience
* Experience of working to protocols or guidelines.
* Experience in frailty care, chronic disease management, and care planning in community or primary care settings
* CDM Management
* Ongoing evidence of CPD
* Experience of offering mentorship and supervision to other nursing staff.
* Experience of developing and implementing training programs.
* Experience of working in care homes
Other
* Meets DBS reference standards and criminal record checks
* Willingness to work flexible hours when required to meet work demands
* Access to own transport and ability to travel across the locality to visit people in their own homes.
* Awareness of data protection (GDPR) and confidentiality issues particularly within a healthcare setting.
Qualifications
* Batchelor Degree in Life Science/Biomedical/Nursing or Allied Health Science or equivalent
* Health & Care Professions Council (HCPC) registration.
* Able to operate at an advanced level of clinical practice, using Level 7 capabilities as defined by (NHE/I GP DES, ARRS funding) and HEE guidance.
* Undergraduate attainment at minimum of Framework for Higher Education Qualification (FHEQ) Dip. HE. In a relevant subject.
* Full UK driving license and access to vehicle (for home visits as required
* Minimum 3 years post-registration experience.
Specialist knowledge/skills
* IT literate / proficient in the use of the computer
* Excellent interpersonal and organisational skills
* Good problem solving and decision-making skills
* Ability to manage workload effectively
* A high standard of clinical skills and experience of using these skills in different situations.
* Willingness to always work towards the best interest of the patient.
* Team player / ability to liaise effectively with colleagues and other members of the multi-disciplinary team.
* Ability to write comprehensive, accurate clinical notes, implement and evaluate care plans.
* Understand own scope of practice, the context of continual learning and the need to develop constantly to ensure safe, competent and confident practice.
* Evidence of success in efficient and effective project and program management
Personal attributes & abilities
* Ability to co-ordinate and prioritise workloads able to multi-task as well as be self-disciplined and highly motivated.
* High degree of personal credibility, emotional intelligence, patience, and flexibility
* Ability to cope with unpredictable situations.
* Confident in facilitating and challenging others
* Demonstrates a flexible approach to ensure patient care is delivered.
Disclosure and Barring Service Check
This post is subject to the Rehabilitation of Offenders Act (Exceptions Order) 1975 and as such it will be necessary for a submission for Disclosure to be made to the Disclosure and Barring Service (formerly known as CRB) to check for any previous criminal convictions.
£48,000 to £48,000 a year Dependant on experience & Pro Rata
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