About this role
Job summary
We are excited to be recruiting 2 Frailty Nurses to join our PCN to support the 2 Integrated Neighborhood Teams across Nuneaton & Bedworth.
This is a brand new role that is intended to work as part of our Multi-Disciplinary Teams to proactively identify, assess and manage patients living with frailty - to support the INT agenda.
The role is designed to reduce avoidable hospital admissions, improve continuity of care for frail and elderly patients, and strengthen coordination between general practice, care homes and the wider community and social care services.
Main duties of the job
As this is a new role, it is anticipated that the role will develop and grow over time.
Primary Care is also in a place of transition with the introduction of Integrated Neighborhood Teams, and the anticipated evolution of Primary Care Networks into INTs.
This is a really exciting opportunity for us to drive how these initiatives are developed and delivered.
It is anticipated that you will work with colleagues across Primary Care, Secondary Care, Social Services and Local Authorities to support our moderate and severely frail patients to reduce A&E attendances and hospital admissions.
About us
We are a large PCN incorporating 11 member practices across Nuneaton and Bedworth. We are supporting 2 INTs (Nuneaton and Bedworth & Bulkington), which represent patients from 19 local practices.
We have a dynamic and supportive PCN Board, and an established Senior Management Team that work really well together to develop ideas and initiatives for new ways of working to support our workforce and patient population.
We are currently developing a management team to support the delivery of INT requirements, which will include leads for Frailty, Care Homes, End of Life and MDT working to ensure that the services we are delivering for our patients is the best it can be.
We have a significant workforce of about 75 staff working across the PCN and supporting our Enhanced Access service. We pride ourselves on the fact that we have a very small turnover of staff, which is indicative of how much our staff are valued and supported and the culture of our PCN.
Job description Job responsibilities
Main Responsibilities
These responsibilities are for an identified cohort of patients.
Clinical Care
Proactively identify patients with moderate to severe frailty using recognised frailty indices and practice registers Undertake comprehensive geriatric assessments (CGA), including functional, cognitive, social, and medication review Develop, document, and regularly review personalised care and support plans in partnership with patients, families and carers Identify patients at risk of unplanned hospital admission and initiate proactive interventions to reduce that risk Support patients and families with advance care planning discussions, including ReSPECT forms and end-of-life wishes, escalating to GPs or specialist palliative services as appropriate Recognise and respond appropriately to signs of clinical deterioration, escalating to GPs or emergency services where necessary Care Home Ward Rounds
Deliver structured weekly ward rounds at designated care homes Review resident health status, medication, and care plans in collaboration with care home staff Liaise with GPs to action clinical decisions arising from ward rounds Build strong working relationships with care home managers and staff to support early identification of resident health concerns Multidisciplinary Working
Present complex and high-risk frailty patients at the monthly INT MDT meeting, providing clinical summaries and care plan updates Coordinate input and follow-up actions from MDT discussions across relevant services Work collaboratively with PCN Pharmacists, Social Prescribers, Care Coordinators and community teams to deliver joined-up, patient-centred care Act as a point of clinical liaison between general practice and community/social care services for frailty patients Administration and Governance
Maintain accurate, timely clinical records in line with practice and PCN information governance policies Contribute to PCN frailty data collection, audit, and outcome reporting Participate in relevant clinical audits and quality improvement initiatives Attend PCN and practice meetings as required Professional Development
Maintain NMC registration and up-to-date clinical competencies Participate in regular clinical supervision, appraisal, and revalidation processes Undertake training relevant to frailty, gerontology, and long-term condition management Keep up to date with national and local guidance relevant to frailty care (e.g. NICE, BGS, local ICB pathways)
Person Specification
Experience Essential
Significant post-registration nursing experience Experience working with frail, elderly or complex patients in community settings Experience presenting at or contributing to MDT meetings
Desirable
Experience of working in a general practice setting Experience of working in a care home setting
Personal Attributes Essential
Highly organised to manage workload Collaborative team player Driver with access to a car to be able to travel between sites, predominantly across Nuneaton and Bedworth
Qualifications Essential
Registered Nurse with current NMC registration Level 7 Frailty qualification
Desirable
Independent Prescribing qualification Other long-term conditions qualifications
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 Nuneaton & Bedworth Primary Care Network
Address Manor Court Surgery
5 Manor Court Avenue
Nuneaton
Warwickshire
CV11 5HX
United Kingdom
Employer's website https://www.nuneatonandbedworthpcn.co.uk/ (Opens in a new tab)