Job description

Job responsibilities

The Frailty service is a planned proactive service maintaining the health and wellbeing of people living with frailty.

The post holder will work as part of a multi-disciplinary team in a patient-facing role across the East Cornwall Primary Care Network, to help improve patient outcomes, ensure better access to healthcare and support practices to manage their most vulnerable and complex patients. The role is pivotal to improving the quality of care and operational efficiencies so requires motivation and passion to deliver excellent services within general practice.

Job Purpose:

To establish a Frailty Service for East Cornwall PCN

• To identify those living with frailty within the PCN, utilising the Rockwood scoring system or other identified method.
• To support the elderly to age healthier, reducing progression of frailty and risks associated with it where possible.
• To support them to make informed choices as to their health and welfare.
• To attend and lead MDTs and work collaboratively with neighbourhood teams to support elderly and carers.
• Reduce emergency hospital admission, readmission and try to reduce care burden.
• Support early discharge planning
• To identify those likely to be within their last year of life and support them to plan for their future needs.
• Develop shared care and support plans by involving older people living with frailty, their families and carers throughout all stages of progression.
• Early identification and treatment of Delirium.

Core Responsibilities

• Develop, implement and evaluate a seamless Frailty support service across the PCN, working with community and secondary care where appropriate, and aimed at continuously improving standards of patient care and wider multi-disciplinary team working.
• Where appropriate, support the development of discharge and contingency plans with relevant professionals to arrange on-going care in residential, care home, hospital, community settings and at home;
• Periodically review, evaluate and change rehabilitation programmes to rebuild lost skills and restore confidence;
• Advise on home, and workplace environmental alterations, such as adjustments for wheelchair access, technological needs, and ergonomic support;
• Advise patients, and their families or carers, on specialist equipment and organisations that can help with daily activities;
• Assist patients to adapt to and manage their physical and mental health long-term conditions, through the teaching of coping strategies; and assess, plan, implement, and evaluate treatment plans, with an aim to increase patients productivity and self-care;
• Ensure delivery of best practice in clinical practice, caseload management, education, research, and audit, to achieve corporate PCN and local population objectives.
• Advise practices of workflow and develop SOPs for team and practices to follow and implement, particularly Personalised Care Planning, utilising best practice.

Multi-disciplinary team working (MDT)

• Ensure MDTs adhere to the Gold Standard Framework and lead MDT development and best practice across the PCN.
• Ensure the right people are involved in MDTs from the East Cornwall Neighbourhood teams and PCN teams.
• Participate in GP huddles and any other PCN/Partnership MDT and promotes effective ways of working;
• Exercise a critical understanding of personal scope of practice and to identify when a patient requires escalation or referring on to other services.
• Develop effective working relationships with the Palliative Care Team and embed new processes and ways of working if required, to avoid duplication and to enhance the patient and family experience.

Communication

The post-holder should recognise the importance of effective communication across the PCN and within the team and will strive to:

• Work with patients through a shared-decision making approach to plan realistic, outcomes-focused goals;
• Coordinate and support the provision of Personalised Care Plans; Treatment Escalation Plans; End of Life Plans;
• Undertake both verbal and non-verbal communication methods to address the needs of patients that have communication difficulties;
• Communicate effectively with other team members;
• Communicates effectively and appropriately with patients and carers complex and sensitive information regarding diagnosis, pathology and prognosis;
• Recognise peoples needs for alternative methods of communication and responds accordingly;
• Develop relationships and a collaborative working approach across the PCN supporting the integration of pathways in primary care.

Signposting

Ensure that patients are referred to the appropriate healthcare professional for the appropriate level of care within an appropriate period of time e.g. pathology results, common/minor ailments, acute conditions, long term condition reviews etc.

Service Development

Contribute to the development and implementation of new services for the PCN.

Information Management

Analyse, interpret and present data to highlight issues and risks to support decision making.

Quality Improvement

• Undertake clinical audits of in areas directed by the PCN, feedback the results and implement changes in conjunction with the practice teams.
• Demonstrates ability to identify and resolve risk management issues according to policy/protocol;
• Follows professional and organisational policies/procedures relating to performance management;
• Represents the Frailty service on relevant committees and meetings, as a lead clinician, provide input in relation to specialist issues and clinical matters as required.

Education and Training

Provide education and training to primary healthcare teams.

Care Quality Commission

Work with the general practice teams to ensure the practice is compliant with CQC standards.

Public Health

To support public health campaigns. To provide specialist knowledge on all public health programmes available to the general public.

Confidentiality

In the course of seeking treatment, patients entrust us with, or allow us to gather, sensitive information in relation to their health and other matters. They do so in confidence and have the right to expect that staff will respect their privacy and act appropriately.

In the performance of the duties outlined in this Job Description, the post-holder may have access to confidential information relating to patients and their carers, practice staff and other healthcare workers. They may also have access to information relating to the practices as a business organisation. All such information from any source is to be regarded as strictly confidential.

Information relating to patients, carers, colleagues, other healthcare workers or the business of the practice may only be divulged to authorised persons in accordance with the practice policies and procedures relating to confidentiality and the protection of personal and sensitive data.

Health and Safety

The post-holder will assist in promoting and maintaining their own and others health, safety and security as defined in the practice Health & Safety Policy, to include:

• Using personal security systems within the workplace according to practice guidelines;
• Identifying the risks involved in work activities and undertaking such activities in a way that manages those risks;
• Making effective use of training to update knowledge and skills;
• Using appropriate infection control procedures, maintaining work areas in a tidy and safe way and free from hazards;
• Reporting potential risks identified.

Equality and Diversity

The post-holder will support the equality, diversity and rights of patients, carers and colleagues, to include:

• Acting in a way that recognises the importance of peoples rights, interpreting them in a way that is consistent with practice procedures and policies, and current legislation;
• Respecting the privacy, dignity, needs and beliefs of patients, carers and colleagues.

Personal/Professional Development

The post-holder will participate in any training programme implemented by the PCN as part of this employment, such training to include:

• Participation in an annual individual performance review, including taking responsibility for maintaining a record of own personal and/or professional development.
• Taking responsibility for own development, learning and performance and demonstrating skills and activities to others who are undertaking similar work.

Quality

The post-holder will strive to maintain quality within the PCN and will:

• Alert other team members to issues of Clinical Governance issues, quality and risk; participate in any risk reviews;
• Assess own performance and take accountability for own actions, either directly or under supervision;
• Contribute to the effectiveness of the team by reflecting on own and team activities and making suggestions on ways to improve and enhance the teams performance;
• Work effectively with individuals in other agencies to meet patients needs;
• Effectively manage own time, workload and resources. He/she will also contribute to the overall team-working of the PCN putting the needs of the PCN first.
• Contribution towards practices CQC compliance rating of GOOD or above.

Person Specification

Qualifications

Essential

• Registered with the Health and Care Professional Council; or Nursing and Midwifery Council;

Desirable

• Holds a masters level qualification;
• May hold or be working towards a prescribing qualification;

Experience

Essential

• Demonstrates general skills and knowledge in core areas;
• Experienced in developing and implementing Personalised Care Plans;
• Is able to plan, manage, monitor, advise and review general frailty care programmes for patients in core areas, including disease states/ long term conditions identified by local Needs Assessment;
• Demonstrates accountability for delivering professional expertise and direct service provision;
• Able to follow legal, ethical, professional and organisational policies/procedures and codes of conduct.
• Full driving licence

Education, Training and Development

Essential

• Demonstrates self-development through continuous professional development activity;
• Demonstrates an understanding of current educational policies relevant to working areas of practice and keeps up to date with relevant clinical practice;
• Ensures appropriate clinical supervision is in place to support development;
• Enrolled into review and appraisal systems within PCN.

Collaborative Working Relationships

Essential

• Operate as a full member of the primary care team, including contributing service evaluation/improvement and research activity;
• Manage and co-ordinate the care that individual patients receive, including through liaising with other members of the MDT and with patients' carers;
• Facilitate primary care activity, with a strong emphasis on prevention and early intervention, including through the delivery of public health advice (e.g. relating to physical activity, weight management and smoking cessation);
• Contribute to the use of healthcare technologies to optimise the integration of service delivery (across teams, sectors and settings) and patients access and continuity of care;
• Contribute to the development of primary care teams, including through contributing to others' learning.

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

Kernow Health CIC

Address

Rame Group Practice

Trevol Road

Saltash

Cornwall

PL11 2TB

United Kingdom

Employer's website

https://www.kernowhealthcic.org.uk (Opens in a new tab)