Job Description

:

The Specialist Community Practitioner (Frailty) plays a vital role in delivering high-quality, patient-centred care to individuals experiencing frailty within the community setting. This role involves working collaboratively with multidisciplinary teams to assess, plan, and implement tailored interventions aimed at improving health outcomes and maintaining independence for vulnerable populations. The practitioner will serve as a key point of contact for patients, their families, and caregivers, ensuring seamless coordination of care and support services.

Job Summary

The post holder will work as a member of the community advanced practitioner nursing team delivering care to frail patients within their own homes whether residential, nursing, learning disability homes or visiting people in their own homes where your knowledge and skill set would enhance quality of care to that person. The post holder will contribute toward ensuring parity of access and support to the team expertise for patients belonging to Haven PCN with a learning disability who reside within a residential home, to people living with frailty and end of life care needs residing within their own homes. The post holder will have proven development of knowledge and skills within the realms of frailty and the care of people living with long term needs of varying complexity including long term condition management, management of increasing frailty, dementia and end of life care.

As a Community Specialist Practitioner the post holder will be supported within their personal and professional development to gain increasing autonomy in professional clinical decision making developing comprehensive assessment and care management skills to meet the acute and ongoing needs presented always acting within their own scope of professional practice supported within the frailty Advanced Practitioner team and GP as appropriate.

We are looking for a motivated individual who has an interest in the care of what can be a diverse population including young and elderly residents and a community population living with frailty, complex and palliative care needs with a commitment to providing a high-quality safe service supported by excellence in clinical practice. You will work with the team members to triage and deal with requests for same day/urgent visits and support the management of the daily visit workload liaising as necessary with our home visiting paramedic colleagues where your skills and expertise best serve the needs of that patient.

The purpose of the frailty team is to improve the quality of health and well-being and where appropriate ensure excellence in end of life care for people within their own home homes for those registered to with a Haven GP practice. The post holder will be very familiar with requirements as set out in Enhanced Health in Care Homes and strive to ensure the best proactive personalised care support and management plans to meet the individual needs of all within your care, fundamental to which is good communication with families, carers and colleagues.

Hours of work will reflect general practice hours.

Main duties & responsibilities

Work as a Community Specialist practitioner to assess, diagnose, plan, implement and evaluate interventions and treatments for patients within their scope of professional practice. Support the transfer of patients between their own home and acute / community hospitals ensuring there is continuity of care at admission and post discharge. Be able to display autonomy within their scope of practice whilst being supported to make clinical judgements on a range of complex issues which may require analysis, interpretation of information to make a diagnosis and management plan that is safe and appropriate, including referral to acute services where required. Conduct regular care plan reviews at a frequency appropriate to the patient's needs ensuring personalised care and support plans for individuals. Ensure patients and carers and or advocates views are taken into account in every stage of the decision making process with sound documentation to clearly understand how decisions were made. Manage and respond to an array of clinical documents within a timeframe appropriate to need which then may require further referral, investigation, prescription or liaison with other specialists as is required. Be able to identify clinical emergencies, deteriorating patients or patients at risk of deterioration ensuring prioritising timely and appropriate actions to promote quality and safety of care delivery. Always work within own individual scope of practice and competence ensuring to seek advice and or support from other senior colleagues or GP's within Haven PCN as required. To be able to fully assess, tolerate and manage risk and deal with uncertainty within individuals personalised care plans and ensuring communication with all relevant parties appropriately where such needs are present. Share knowledge and expertise, acting as an expert resource to others. To attend and participate in practice clinical meetings and other multi-disciplinary meetings where necessary and communicate appropriately.
PERSON SPECIFICATION

Qualifications

Essential

Registered Nurse on the NMC register Non-Medical Prescribing qualification Completion of clinical skills module or equivalent Evidence of continual professional development and the practical application of new skills to the workplace
Desirable

Mentoring/teaching qualification Specialist knowledge within specific long term conditions. Specialist knowledge within frailty and or palliative care.
Knowledge & Experience

Essential

Able to demonstrate a good understanding of the specialist practitioner nursing role related to older people and people with complex care needs. Familiar with requirements of specific assessments expected within care of older frail people ie Complex geriatric assessment, 4AT, GPCOG etc To demonstrate a sound working knowledge of current issues within the NHS To demonstrate knowledge of management of patients with complex health or long term conditions To have a good understanding of the range of needs people within nursing and residential care may present. To have understanding of and experience working within the community. To have experience working with people with complex learning disability needs. Supervisory skills Experience of a clinical software system
Desirable

Experience of primary care Experience of working with frail/elderly patients Experience palliative / end of life care Professional development within care of people with Learning Disabilities Knowledge of Enhanced Care for Older People (ENCOP) with willingness to complete Essential and Specialist levels and pertinent Advanced Domains over time
Skills & Abilities

Excellent communication skills including the ability to communicate complex information about conditions and treatment plans where there may be barriers to understanding from patients, their carers and other professionals Displays self-confidence and self-awareness in dealing with patients and staff Contrasting abilities to work both in teams and independently Able to articulate the rationale for decisions Able to address and solve complex problems Able to document observations, results, decisions and actions To have sound understanding of the relevant legal/clinical frameworks including NICE guidance, Mental Capacity Act and Safeguarding. Excellent organisational skills Ability to identify, practise and manage critical issues and multiple priorities Ability to work under pressure Flexible and adaptable approach Committed to personal and professional development

For a copy of the Full job description and Person Spec please email:

nencicb-cu.havenpcn@nhs.net

Job Type: Part-time

Pay: 47,810.00-54,710.00 per year

Work Location: In person