About this role
Job summary
Working alongside the INT Clinical Lead, you will help shape & deliver high-quality, proactive, person-centred care for people living with frailty across the our neighbourhood.
This new senior clinical role offers the opportunity to lead the development of innovative frailty services, supporting early identification, comprehensive assessment & coordinated interventions that help people maintain independence, wellbeing & dignity at home.
You will champion evidence-based practice, provide expert clinical leadership & work collaboratively across primary care, community services, social care, voluntary organisations & secondary care. A key focus will be supporting practices & multidisciplinary teams across health, social & voluntary care to develop & embed a comprehensive frailty programme, ensuring people receive the right care, at the right time, in the right place.
The postholder will play a key role in service transformation, improving quality, developing integrated pathways & identifying more effective ways of working. You will also support monitoring, evaluation & reporting to measure the impact of new initiatives & drive continuous improvement.
This is an exciting opportunity for an experienced, forward-thinking clinician passionate about integrated care and improving outcomes for people living with frailty.
Part-time working (min 0.8 FTE) & Secondment opportunities will be considered for the right candidate. Secondment applicants must have line manager approval before applying
Main duties of the job
Provide strategic direction and monitor progress to achieve South Kerrier Neighbourhood objectives.
Where appropriate advocate for change across South Kerrier to bring together community and practice teams.
Develop, implement and evaluate a seamless Proactive/Frailty support service across South Kerrier, working with community and secondary care where appropriate, and aimed at continuously improving standards of patient care and wider multi-disciplinary team working.
Where appropriate, support the development of discharge and contingency plans with relevant professionals to arrange on-going care in residential, care home, hospital, community settings and at home;
Assist patients to adapt to and manage their physical and mental health long-term conditions, through the teaching of coping strategies; and assess, plan, implement, and evaluate treatment plans, with an aim to increase patients productivity and self-care;
Ensure delivery of best practice in clinical practice, caseload management, education, research, and audit, to achieve South Kerrier local population objectives.
Advise practices of workflow and develop SOPs for teams and practices to follow and implement, particularly Personalised Care Planning, utilising best practice.
About us
The South Kerrier Integrated Neighbourhood Team (INT) supports a diverse and vibrant population of more than 33,000 people across communities including Helston, Carleen, Coverack, Constantine and the surrounding rural areas. We are a collaborative, communityrooted team bringing together colleagues from health, social care, the voluntary sector, &independent providers to deliver joinedup, personcentred care.
Our shared purpose is simple: to help people live well, stay well, and receive the right support at the right time. By working as one team across organisational boundaries, we aim to reduce fragmentation, improve access to care, and strengthen the resilience of our local communities.
A key focus for our INT is enhancing the support available for people living with frailty. This includes proactive identification of those who may benefit from early intervention, as well as responsive, coordinated care during periods of crisis or following events such as hospital admissions. We work closely with primary care, community services, social care teams, and voluntary partners to ensure that individuals and their families feel supported, informed, and empowered.
We are a team that values innovation, collaboration, and compassion. Whether we are redesigning pathways, supporting neighbourhood initiatives, or working directly with individuals in their homes, we are committed to improving outcomes & delivering care that reflects the strengths & needs of the our community.
Job description Job responsibilities
Core Responsibilities
Provide strategic direction and monitor progress to achieve South Kerrier Neighbourhood objectives.
Where appropriate advocate for change across South Kerrier to bring together community and practice teams.
Develop, implement and evaluate a seamless Proactive/Frailty support service across South Kerrier, working with community and secondary care where appropriate, and aimed at continuously improving standards of patient care and wider multi-disciplinary team working.
Where appropriate, support the development of discharge and contingency plans with relevant professionals to arrange on-going care in residential, care home, hospital, community settings and at home;
Assist patients to adapt to and manage their physical and mental health long-term conditions, through the teaching of coping strategies; and assess, plan, implement, and evaluate treatment plans, with an aim to increase patients productivity and self-care;
Ensure delivery of best practice in clinical practice, caseload management, education, research, and audit, to achieve South Kerrier local population objectives.
Advise practices of workflow and develop SOPs for teams and practices to follow and implement, particularly Personalised Care Planning, utilising best practice.
Service Leadership
Provide professional leadership for the proactive care frailty service, offering guidance and support to the Proactive Nursing Team and neighbourhood clinical staff. Maintain clinical oversight of complex frailty patients, including providing direct clinical review where appropriate, to ensure safe and coordinated care across the neighbourhood team. Lead workforce planning, allocation of resources, and performance monitoring in collaboration with operational managers.
Ensure robust clinical governance structures are maintained, including incident review and risk management.
MDT
Ensure MDTs adhere to the Gold Standard Framework and lead MDT development and best practice across South Kerrier.
Ensure the right people are involved in MDTs from the South Kerrier Neighbourhood teams.
Participate in GP huddles and any other Partnership MDT and promote effective ways of working;
Exercise a critical understanding of personal scope of practice and to identify when a patient requires escalation or referring on to other services.
Develop effective working relationships with the Palliative Care Team and embed new processes and ways of working if required, to avoid duplication and to enhance the patient and family experience
Complex Case Management
Hold a case load of patients across South Kerrier.
Prescribe within your individual scope of practice and ensure that prescribing is undertaken in a safe, cost-effective manner.
Person Specification
Education Training and Development Essential
Demonstrates self-development through continuous professional development activity; Demonstrates an understanding of current educational policies relevant to working areas of practice and keeps up to date with relevant clinical practice; Ensures appropriate clinical supervision is in place to support development; Identify opportunities for cross profession learning and skills acquisition ensuring appropriate education is developed, delivered and evaluated; Enrolled into review and appraisal systems within PCN.
Leadership Essential
Demonstrates understanding of the Proactive care service and is able to implement this appropriately within the workplace; Demonstrates understanding of, and contributes to, the implementation of South Kerrier Neighbourhood team vision; Demonstrates ability to improve quality within limitations of service; Reviews yearly progress and develops clear plans to achieve results within priorities set by others; Demonstrate ability to motivate self to achieve goals; Promotes diversity and equality in people management techniques and leads by example.
Desirable
Engages with Patient Participation Groups (PPGs) and involves PPGs in development of the role and practices
Experience Essential
Working at masters level or equivalent that encompasses the four pillars of clinical practice, leadership and management, education and research and adheres to the Multi professional framework for advanced clinical practice. Is able to plan, manage, monitor, advise and review general frailty care programmes for patients in core areas, including disease states/ long term conditions identified by local Needs Assessment; Demonstrates accountability for delivering professional expertise and direct service provision; Demonstrates problem-solving skills underpinned from perspectives and different models; Able to follow legal, ethical, professional and organisational policies/procedures and codes of conduct. Comprehensive digital skills to use different clinical systems; health applications for self-supportive care; risk stratification tools and general Microsoft office suite products.
Research and Evaluation Essential
Critically engage in research activity adhering to good research practice guidance so that evidence-based strategies are developed and applied to enhance quality, safety and productivity and value for money; Evaluate and audit own and others clinical practice selecting and applying valid reliable methods then acting on the findings; Demonstrates ability to generate evidence suitable for presentations at Neighbourhood level; Develop and implement robust governance systems and systematic documentation processes keeping the need for modification under critical review.
Qualifications Essential
Registered clinician. Educated to Masters level in Advanced Practice. Non-Medical Prescribing qualification. Evidence of management/leadership qualification/training. Evidence of continual professional development and the practical application of new skills to the workplace.
Collaborative Working Relationships Essential
Operate as a full member of the primary care team, including contributing service evaluation/improvement and research activity; Able to work across organisations and in a matrix management style to bring together different teams across a large area; Manage and co-ordinate the care that individual patients receive, including through liaising with other members of the MDT and with patients' carers; Facilitate primary care activity, with a strong emphasis on prevention and early intervention, including through the delivery of public health advice (e.g. relating to physical activity, weight management and smoking cessation); Contribute to the use of healthcare technologies to optimise the integration of service delivery (across teams, sectors and settings) and patients access and continuity of care; Contribute to the development of primary care teams, including through contributing to others' learning.
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.
UK Registration
Applicants must have current UK professional registration. For further information please see NHS Careers website (opens in a new window).
Employer details Employer name Helston Medical Centre & Porthleven Surgery
Address Trelawney Road
Helston
Cornwall
TR13 8AU
United Kingdom
Employer's website https://www.helstonmedicalcentre.co.uk/ (Opens in a new tab)