Frailty NurseNHS

Job summary

Cheltenham Peripheral Primary Care Network is a group of 5 Practices situated around the edge of Cheltenham. We collaborate as a Network as we truly believe by working together we can achieve better and greater care for our patients in the communities.

We have an established Frailty Team for the Cheltenham Peripheral PCN which is a multi-disciplinary team dedicated to supporting patients who are frail, elderly or vulnerable and living in the community. The team has been created specifically by the Cheltenham Peripheral Network to recognise the needs of the local population and the scope for transforming services to provide personalised care.

The role of the frailty nurse supports CP PCNs plan to reduce the number of frail older people who have a lack of support, who want to continue living in their own homes and require access to some additional care. Cheltenham Peripheral want to establish a standardised approach to supporting frail patients in the community. The need for this has arisen because routine and unscheduled care has not changed in line with the needs of an ageing population. Older people can live with several health conditions and a gradual decline may be missed until a crisis occurs preventative work can help to avoid the person reaching a crisis.

Main duties of the job

The Frailty Nurse will work alongside our established Frailty team in developing close relationships with our five GP practices, supporting them to:

Establish systems and co-ordinate patient access to services.

Delivering the Gloucestershire Model of Frailty.

Enable smooth and planned transfer between care settings.

Provide advice and information.

Oversee safeguarding administration and communication with partner organisations where required.

Ensure personalised health and care planning is proactive, supportive and patient-centred.

Job description

The Frailty Nurse is a highly skilled healthcare practitioner who will work alongside our existing Frailty Nurse who is responsible for delivering proactive, personalised care to individuals living with frailty in community settings. This role interfaces with primary, secondary, social care and VCSE organisations. ensuring holistic management of frailty. With a focus on prevention, the role is pivotal in the delivery of the NHSE Proactive Care Framework at PCN level for people living with moderate or severe frailty, working collaboratively with multi=disciplinary teams (MDTs) and system partners to enhance independence and quality of life an in turn reduce the risk of unplanned hospital admissions. A key element of the role is to work with people living with frailty in a strength based, collaborative way that focuses on what matters to them.

About us

The Leckhampton Surgery, Stoke Road Surgery, Sixways Clinic, Winchcombe Medical Centre and Cleevelands Medical Centre work together as the Cheltenham Peripheral Primary Care Network. Working in Multidisciplinary teams our Pharmacists, Social Prescribers, Care-Coordinators, Mental Health Practitioners, Physician Associates and Pharmacy Technicians support our GP and Nursing Colleagues to provide a high level of care to patients.

The Frailty nurse will work alongside care co-ordinators and social prescribing link workers to provide an all-encompassing approach to personalised care and promoting and embedding the personalised care approach across the PCN