Job description

Job responsibilities

Care homes and community-based care

The post holder will support older people in care homes and the community, reviewing patients after a change in health, supporting falls prevention and care planning, liaising with care home staff and families, and helping to reduce avoidable emergency attendances or admissions.

Frailty assessment

The post holder will:

• Identify patients with mild, moderate, or severe frailty.
• Review relevant medical, functional, and social information.
• Assess functional ability and any change from the patient's normal baseline.
• Identify recent or recurrent falls, and mobility or balance difficulties.
• Recognise possible cognitive impairment or delirium, and escalating where needed.
• Identify nutritional concerns, weight loss, or poor appetite.
• Consider continence and toileting difficulties and making appropriate referrals
• Identify potential medication-related contributors to decline.
• Consider social isolation, carer strain, and the home environment and making appropriate referrals.
• Recognise red flags that need urgent medical review.
• Communicate findings clearly to the wider team.

Holistic clinical assessment

Within their professional scope, the post holder will:

• take a clinical history;
• review medical records, diagnoses, and recent hospital or community contacts;
• assess changes from baseline and consider functional status, multimorbidity, and safeguarding concerns.
• Identify possible infection, dehydration, malnutrition, delirium, or falls as causes of decline, and recognise when further investigation or medical assessment is required.

Managing frailty syndromes

• The post holder helps identify and manage common frailty syndromes, including falls, reduced mobility, functional decline, cognitive impairment, delirium, nutritional decline, continence problems, dizziness, polypharmacy, social isolation, and carer stress.
• They identify appropriate interventions within their scope and coordinate referrals to other services, such as GPs, community nursing, physiotherapy, occupational therapy, dietetics, pharmacy, falls services, specialist frailty or memory services, social care, and palliative care where appropriate.

Clinical decision-making

• The post holder demonstrates sound clinical reasoning appropriate to Band 6 level, making independent decisions within their scope, recognising significant deterioration, and balancing clinical evidence with the patient's circumstances and preferences.
• The post holder would identify the limits of their own knowledge or experience, seek advice from senior clinicians, GPs or specialists when needed, escalate promptly where safety may be at risk, and document their reasoning clearly.

Multidisciplinary working

The post holder works closely with GPs, practice nurses, pharmacists, advanced practitioners, community nurses, allied health professionals, social workers, care coordinators, care homes, and specialist or secondary care services, contributing relevant clinical information to MDT discussions for patients with complex needs.

Safeguarding

The post holder recognises and responds appropriately to safeguarding concerns involving older people, including neglect, abuse, carer breakdown, and unsafe living circumstances, following practice and local safeguarding procedures.

Supervision and governance

The post holder has access to a named senior clinician and GP support, takes part in regular clinical supervision, reflective practice, and audit, and maintains appropriate professional indemnity. They work within relevant professional standards and the practice's clinical governance policies.

Continuing professional development

The post holder maintains ongoing development relevant to frailty, falls, delirium, dementia, nutrition, multimorbidity, medicines awareness, safeguarding, mental capacity, and end-of-life care, identifying learning needs through supervision, appraisal, and clinical practice.

Quality improvement

The post holder contributes to safe and effective frailty services through audit, service evaluation, review of falls and hospital admissions, development of care pathways, and MDT learning, supporting a culture of continuous improvement and patient safety.

Person Specification

Experience

Essential

• Post registration experience gained by undertaking on-going personal development and training.
• Experience of working with patients with frailty, including being able to identify different levels of frailty and how that effects the patient.
• Experience in clinically assessing patients independently, arranging investigations, considering differential diagnoses and implementing management plans.
• Experience of working with long-term conditions.
• Good understanding of current health care issues.

Desirable

• Involvement in the implementation and management of change.
• Experience underpinned by knowledge of working with and understanding the complex needs of patients in a primary care/community setting.

Skills and Abilities

Essential

• Excellent communication and interpersonal skills.
• Ability to holistically and independently assess a frail patient.
• Ability to advocate patient issues.
• Ability to demonstrate leadership skills.
• Excellent organisation skills including the ability to make decisions and prioritise.
• A degree of autonomy, analytical skills and multidisciplinary knowledge in caring for patients.
• Decision making skills and problem solving skills.
• Ability to understand and interpret information/evidence based care and apply to practice.
• Ability to work within your scope and escalate safely and appropriately when required.
• Critical thinking.
• Good IT skills.
• Assertive, adaptable and flexible.
• Empathy and compassion.

Desirable

• Experience of completing Comprehensive Geriatric Assessments.

Qualifications

Essential

• Experience and fully qualified Healthcare professional.
• Registered Practitioner holding current registration with NMC or HCPC.

Desirable

• Frailty or End of Life Care modules/qualifications.
• Clinical assessment module if not included in your registration qualification.

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

Whitstable Medical Practice

Address

Estuary View Medical Centre

Boorman Way

Whitstable

Kent

CT5 3SE

United Kingdom

Employer's website

https://www.whitstablemedicalpractice.co.uk/ (Opens in a new tab)