Frailty Nurse Specialist

The Frailty nurse specialist will be responsible for providing the delivery of evidence based and clinically effective practice within the community to facilitate step down from the acute hospitals and step up from the community. To promote effective self-management of patients preventing unnecessary hospital admissions and improving quality of life and to actively identify patients who would benefit from an admission to the virtual ward.

The post holder should be an experienced community nurse, with diagnostic and consultation skills and preferably be a non-medical prescriber or willing to complete the course and will act within their professional boundaries, providing care for the presenting patient, from initial history taking through to treatment. They will work collaboratively with the multi-disciplinary team to meet the needs of the patients.

Key responsibilities of the post holder are to consolidate skills of critical analysis and evaluation, to enable knowledge pertaining to complex contemporary community nursing practice. The post holder will use innovative practices to manage complex community situations in challenging environments. Take responsibility for developing and changing practices within the community.

To be responsible for the efficient management of the Mid Essex Frailty Virtual Ward central point of access (hub) when allocated to the hub

To undertake comprehensive geriatric assessments for patients under the care of the Frailty Virtual Ward and formulate personalised management plans in collaboration with the MDT. This includes chronic, acute and palliative care within own competencies, recognising own limitations and seeking advice when necessary. This will include continuously evaluating and acting on outcomes

To work with others in setting up guidelines for all clinical practice within own professional scope. To assist medical staff by ensuring patients conditions are reported on as necessary and medical instructions are conveyed to patients’, carers and staff as appropriate

To assist in the continued implementation of a multidisciplinary service, whilst working as part of the virtual frailty ward

Undertake risk assessments to manage risk appropriately, ensure that the team follows recommendations accordingly

Following a risk assessment, report to Line Manager any deficit in the provision of service, equipment and staff

Provide is a Community Interest Company (social enterprise). We deliver a broad range of health and social care services in the community, and are committed to making sure that they are safe, responsive and of high quality. Provide is owned by its employees and has primarily social objectives. Any profits we make are reinvested into the local community or back into delivering services.

We work from a variety of community settings, such as community hospitals, community clinics, schools, nursing homes and primary care settings, as well as within people’s homes to provide more than 40 services to children, families and adults across Essex, Dorset, East Anglia and the North of England.

A highly respected, award winning health and social care provider. We expect our staff to demonstrate and uphold our values at all times:

Vision: Transforming Lives

Values: Care, Innovation and Compassion

Mission: An ambitious, employee owned social enterprise, growing in size and influence. We transform lives by treating, caring and educating people.

Provide is an equal opportunity employer committed to building a team that represents a variety of backgrounds, perspectives and skills, proud to have LGBT+ and Ethnic Minority Networks.

We welcome applicants from underrepresented groups. If you have the skills and experience for the job, please apply regardless of your background.

Eligible for NHS Pension

Clinical Responsibilities

• To be responsible for the efficient management of the Mid Essex Frailty Virtual Ward central point of access (hub) when allocated to the hub
• To act as an autonomous, registered practitioner who is legally and professionally accountable for own unsupervised actions guided by the professional code of conduct and Trust guidelines and protocols
• The post holder will have Current Effective Status on the Nursing and Midwifery Council (NMC) – Registered Nurse
• Further professional knowledge will have been gained through accredited courses workshops, study and in-house training programmes
• To be responsible, and accountable, for service delivery to clients/patients.
• To undertake comprehensive geriatric assessments for patients under the care of the Frailty Virtual Ward and formulate personalised management plans in collaboration with the MDT. This includes chronic, acute and palliative care within own competencies, recognising own limitations and seeking advice when necessary. This will include continuously evaluating and acting on outcomes
• To be able to initiate referrals to other health professional specialist services and agencies
• To provide patients and relatives with information and education thus ensuring they have meaningful choices that promote dignity, independence and quality of life
• To ensure practice is supported by research, evidence-based practice, literature and peer review
• To actively promote discharge from the acute sector into the community setting at the earliest possible opportunity and provide in-reach support.
• To provide a visible professional presence where staff, patients, carers, voluntary, statutory and private services can approach for assistance, advice & support to enable provision of holistic care
• To support the effective allocation of daily patient visits, when overseeing the hub
• Attend as part of a rota, virtual GP calls to discuss patients and liaise with the Frailty Consultant for complex medical management
• To ensure patients receive high standards of nursing care by leading on the development of the skills of the registered nurses and support staff
• To participate in training junior colleagues to achieve/maintain their competencies
• To lead on discharges alongside the Multidisciplinary team and ensure length of stay is optimal
• To empower patients and their carers to participate in and make informed choices about their care, ensuring that it is personalised.
• Networking with other multi-disciplinary, statutory, private and voluntary organisations, users, carers and assisting in managing the interfaces between them
• Inspiring others through action and example, challenging traditional practices and encouraging innovative problem solving amongst staff
• To improve outcomes for people with frailty and complex co-morbidities and reduce the need for these people to attend or be admitted into hospital or long-term residential care
• Develop innovative ways of increasing flow in and out of the frailty virtual ward with a particular focus on admission avoidance working in collaboration with the Urgent Community Response Team (UCRT)
• Use advanced specialist knowledge to enable patients & carers to develop self-care skills with respect to health and health services
• To keep an accurate, up to date record of patients’ condition, defining clinical outcomes and providing written communication and timely reports to appropriate agencies e.g. GP’s, Consultants, MDT’s and Social Services
• Following a risk assessment, report to Line Manager any deficit in the provision of service, equipment and staff
• Be responsible for the delivery of safe evidence-based care which is delivered in a timely manner by the right health care professional

Managerial Responsibilities

• To lead on rota management alongside band 7 colleagues
• To monitor team productivity by participating in audits, monitoring sickness, performance management and HR processes
• To deputise for the service lead in their absence ensuring the effective day to day running of the service and attend meetings in their absence
• To lead and co-ordinate on clinical nursing competencies in accordance with local policy and national frailty drivers
• To actively contribute to own 1:1 with Line Manager. To participate in own clinical supervision, appraisal, and PDP in collaboration with Line Manager
• To line manage staff and support individualised professional development via appraisal process and 1-1’s
• To improve quality of services, through use of evidence-based practice projects, standards, audit and measuring outcomes, making recommendations for change where required
• To be actively involved in the collection, selection and analysis of appropriate data and statistics required by the current health governmental bodies
• To work with others in setting up guidelines for all clinical practice within own professional scope. To assist medical staff by ensuring patients conditions are reported on as necessary and medical instructions are conveyed to patients’, carers and staff as appropriate
• To assist in the continued implementation of a multidisciplinary service, whilst working as part of the virtual frailty ward
• To work with others to achieve service aims and objectives
• Work with team and the organisation as a whole towards supporting financial balance
• Undertake risk assessments to manage risk appropriately, ensure that the team follows recommendations accordingly
• Following a risk assessment, report to Line Manager any deficit in the provision of service, equipment and staff
• Manage informal complaints and implement the recommendations following formal complaints
• Actively engages in the recruitment and selection of team members and manages the induction and orientation programmes for new staff
• Implements the National Service Frameworks
• Undertake the role of preceptorship / mentorship as required