About this role
Job summary
A Band 7 Frailty Nurse within North Cheshire and Mersey NHS Trust provides advanced clinical assessment, complex decisionmaking, and proactive case management for adults living with frailty across community settings. The role focuses on preventing avoidable hospital admissions through timely intervention, holistic assessment, and coordination of multidisciplinary care. Working autonomously, the postholder leads frailty pathways, supports Urgent Community Response activity, and delivers personcentred care in patients homes. They provide clinical leadership, supervision, and support to the wider team, contributing to service development and quality improvement. Strong communication, advanced clinical skills, and systemwide collaboration are essential to improving outcomes for people with frailty.
Main duties of the job
Advanced Clinical Practice
Conduct comprehensive frailty assessments, including CGA (Comprehensive Geriatric Assessment). Undertake advanced physical examinations and clinical decisionmaking. Diagnose, plan, implement, and evaluate personalised care plans. Manage complex, multimorbid patients with fluctuating needs. Prescribe or recommend medications (if a nonmedical prescriber). Identify and manage acute deterioration, including escalation where required. Deliver urgent community response (UCR) interventions to prevent hospital admission.
About us
Flexible working will be considered for all roles.
North Cheshire and Mersey NHS Foundation Trust (NCM) serves more than one million residents across the Halton and Warrington boroughs and the wider North West region.
Bringing together community and out-of-hospital services (formerly provided by Bridgewater Community Healthcare) with inpatient and elective care (formerly Warrington and Halton Teaching Hospitals) we provide services at two hospital sites and more than 70 community hubs and facilities.
Our mission, vision and values are at the heart of North Cheshire and Mersey NHS Foundation Trust (NCM).
They underpin everything we do and everything we aspire to be as an organisation.
Our mission
We will be exceptional for our patients, our communities and each other
Our vision
We will be a great organisation providing excellent healthcare and opportunities to work and learn
Our values
Kind: We are caring, supportive and respectful to everyone Open: We are honest, transparent and open to new ways of working Fair: We listen, value our differences and are inclusive to all One team: We work well together and with our communities
Job description Job responsibilities
The post holder will be an integral member of the multi-disciplinary Intermediate care and Frailty crisis response team
The primary function of the role is to maximise the patients health, clinically assess and treat patients in a defined group and reduce risks that contribute to ill health, thereby reducing unnecessary admissions to acute services, reducing demand on GP time, facilitating discharges and the delivery of efficient, effective, co-ordinated and timely high quality care to patients.
The post holder will
Undertake clinical assessment providing advanced nursing, diagnostic treatment for patients within the defined group.
Link with existing services to prevent hospital admission and facilitate early discharge from hospital and prevent re-admission.
Develop Partnerships and joint working within the wider local health and social care economies.
Work collaboratively across organisation boundaries to support the effective and co-ordinated provision of health
Provide clinical triage in the Single Point of Access centre (S.P.A.) on a rotational basis
Duties and Responsibilities
Principal Responsibilities:
(a) ClinicalConduct a comprehensive healthcare assessment, utilising any current information in order to develop an individualised plan of care for patients within a defined group. This will include:
Review of health assessment including medical history
Physical examination
Assessment and review of medication
Making referrals for diagnostic tests
Functional /cognitive assessment
Refer to MDT partners for assessment.
Maintain contemporaneous and accurate clinical records, recording all patient related activity on the clinical systems / databases in accordance with professional body , national legislation and local and national standards
To assess and treat patients, in their own environment, without prejudice and in conditions hazardous to health with the potential to cause harm. To work autonomously within scope of practice and refer to more experienced team members as necessary, in line with the lone worker policy guidelines. To implement best practice based on evidence and clinical knowledge
Develop, monitor and manage the plan of care in collaboration with the MDT and others.
Application of clinical knowledge about long term conditions
Analysis of symptoms and data
Identification of risk factors associated with exacerbation of patients condition
Recognition of early signs and symptoms of acute illness.
Involving patients and carers in the development of the care plan and ensuring that their views and abilities are reflected.
Documentation of progress and continuous reassessment
Referral and investigation
To provide education and advice, spontaneous and planned for patients, carers and other professionals promoting and ensuring a consistent approach to patient care.
To liaise with all members of the multi-disciplinary team in relation to caseload
Set up and actively participates in case review to evaluate the outcomes of care plans including social care needs.
Co-ordinate care and treatment to avoid fragmentation, duplication and delay, in the least intensive setting appropriate to the patients needs by:
Prioritisation and co-ordination of multiple health needs.
Referrals to specialist services.
Ensuring effective communication and sharing of appropriate information amongst professionals to avoid conflicting treatments.
Integration across health and social care (inc. voluntary sector and housing).
Identifying deficiencies in service provision and address these as appropriate
Undertake risk assessment in relation to individuals within the client group
Be aware of and adhere to, the Professional bodies Standards and Code of Conduct.
(b) Clinical Management and Leadership
Contribute to the collection of data to monitor outcomes measures
To accept clinical responsibility for reviewing and triaging referrals and prioritising according to clinical need
Participate in the development of case management across Intermediate care and Frailty Services.
Provide clinical leadership and mentoring to team members and students
Challenge professional and organisational boundaries to ensure that the Case Management role is focused on meeting the needs of patients, thus promoting continuity of high quality patient centred health and social care.
Acts as an advocate and champion for patients in a variety of forums and professional groups and challenges attitudes and behaviours.
Act as a role model so that patients receive the most effective care possible through
Encouraging optimum management of long term conditions to ensure that the patient is functioning at the most independent level possible
Acting in patients interests at all times
Contributing to the development of policy and services to reflect the needs of the patient caseload.
To attend relevant clinical meetings, case conferences and reviews where appropriate. Manage the complex clinical interventions of individuals within an identified patient group on an ongoing basis. Monitor and respond to the development of changing clinical and social situations with the identified patient group without recourse to others where possible. Ensure the safe management of care and service delivery Performing appraisal, personal development reviews and the application of staff management procedures for appropriate staff and in the absence of the 8a Clinical lead . In the absence of the 8a Clinical lead accept managerial and clinical caseload responsibility prioritising accordingly.
Service Development Requirements
Encourage patient participation in case management
The provision of information about disease prevention, progression and outcomes.
Ensure that services are accessible to increase patient confidence
Empowering the patient to self manage whenever possible.
Contribute to the development of role and service redesign in Intermediate care and frailty management.
Analytical and Information Requirements
The postholder will utilise data and data tools (including databases) to produce appropriate monitoring reports on both patient care and service outcomes and produce appropriate communication for patients.
Communication
To use communication skills:
Effectively and sensitively with a flexible approach. To give patients details of their condition, its management and plans of treatment. This may involve explaining the nature of, chronic or disabling conditions and possible poor outcome and response to treatment, and will need to take into consideration emotional, physical and psychological conditions
To gain consent from patients, including those who may have communication problems e.g. English as a second language, hearing loss, other medical conditions which affect communication.
To manage own emotional responses and remain objective, calm, and professional with clients in high emotional and physical distress.
Of motivation and encouragement to ensure active participation in home management programmes, in particular when there may be high levels of pain and anxiety, and /or depression.
Clinical Governance Requirements
Participate in individual and group clinical supervision and take responsibility for developing own learning. To maintain competency to practice through Continuing Professional Development To actively ensure the implementation of and adherence to issues associated with clinical governance, policies and procedures of the Trust Participate in research and audit relating to Intermediate care and Frailty management Ensure systems are in place for ongoing review and assessment of care provision and delivery. Improve quality via Clinical Governance, Essence of Care and Clinical Supervision, by working closely with colleagues to address competency levels within the service. Report any incidents through application of trust policies. Participate in patient satisfaction reporting to improve patient care.
Education and Training Requirements
Promote formal and informal training to pre and post registration health and social care professionals in relation to integrated working and provide mentorship and teaching to others developing a frailty service
Participate in the induction of new staff.
Provide education, advice and support to health and social care staff, people with long term conditions and their carers in both community and acute settings.
Maintain up to date knowledge and competence in line with professional and service requirements and demonstrate critical thinking, decision making and reflective skills to ensure own professional development.
Please find attached full Job Description and Person Specification
Person Specification
Experience Essential
Experience of working with patients with long term conditions and / or frailty including triage of patients Experience of successful multi agency working including an understanding/ experience of working in a social care environment Evidence of influencing, motivating and negotiating with others to achieve change in relation to care Extensive demonstrable post registration experience and evidence of enhanced clinical practice Management/Clinical Leadership experience
Desirable
Experience of work in community
Sponsorship Essential
Please confirm your Right to Work status (share-codes will be checked where applicable).
Job Specific Requirements Essential
Clinical Assessment and skills to undertake the role. Moving and handling skills (including ability to assess need) Clinical decision making Venepuncture Ability to work flexibly over 7 days as required by rotas and between hours of 8am 8pm
Desirable
Palliative/end of life care skills
Qualifications Essential
Relevant Clinical Professional Qualification- Registered Nurse or Allied Health Professional with current NMC or HCPC Registration Degree or Masters level clinical/advanced practice Extensive post registration experience Prescribing qualification at V300 level, working towards or willing to undertake.
Desirable
Evidence of post registration/ qualification study on management of COPD, Diabetes or Coronary Heart Disease Mentorship course/qualification or equivalent experience
Relationships Essential
If you are related to a director or have a relationship with a director or employee of an appointing organisation, please state the relationship.
Skills, Knowledge & Competencies Essential
Understanding of the principles of case management Awareness of long term condition management agenda Awareness of current national and local agenda in health and social care for frailty and intermediate care and the current NHS quality agenda Evidence of being able to communicate complex information and advice on healthcare to patients/carers and colleagues Ability to work under pressure, autonomously and manage a diverse work load Excellent interpersonal skills; including negotiation, influencing and presentation Risk Assessment skills Demonstrable knowledge of risk management processes and clinical governance Ability to understand and analyse complex data Knowledge of and participation in audit Self-management and motivation skills Confidence to challenge traditional practice and persistence to address difficult issues Networking knowledge and understanding of local services Knowledge of current professional & clinical issues Knowledge of Safeguarding Vulnerable Adults procedures Good IT skills
Desirable
Awareness of factors which contribute to good health and the importance of promoting these in line with organisational public health policy Experience of participating in research
Other Essential
The ability to travel independently across the Trust The ability to work flexibly in accordance with service needs Willing to undertake further study if role requires
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.
Certificate of Sponsorship Applications from job seekers who require current Skilled worker sponsorship to work in the UK are welcome and will be considered alongside all other applications. For further information visit the UK Visas and Immigration website (Opens in a new tab).
From 6 April 2017, skilled worker applicants, applying for entry clearance into the UK, have had to present a criminal record certificate from each country they have resided continuously or cumulatively for 12 months or more in the past 10 years. Adult dependants (over 18 years old) are also subject to this requirement. Guidance can be found here Criminal records checks for overseas applicants (Opens in a new tab).
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 North Cheshire and Mersey NHS Foundation Trust (BCH)
Address Urgent Treatment Centre
Oaks Place, Caldwell Road
Widnes
Cheshire
WA8 7GD
Employer's website https://northcheshireandmersey.nhs.uk/ (Opens in a new tab)