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Job description

We are looking for an enthusiastic, experienced and highly motivated Frailty Specialist Nurse (ACP) to join the team working with residents in housing with care schemes.

This role is focused on proactively identifying residents within the housing with care projects to identify those who have unmet healthcare needs, deteriorating health and identify social care needs. There is a focus on health promotion, prevention of admission and following up residents after attendance at hospital and reviewing medication. This post involves wider working with primary care, mental health and learning disability services. The post holder will liaise across all organisational boundaries.

The post holder will have knowledge of conditions common to older people, including dementia, delirium, frailty and falls and complex therapeutics, identification of residents who are approaching end of life and what interventions need to be put into place.

The post holder requirements:

• Perform independent clinical assessments, using the comprehensive Geriatric Assessment where appropriate, with frail older adults and recommend appropriate care strategies
• Be a highly visible and proactive leader acting as a clinical resource for the Care Home Support Team and ensuring the sustained delivery of high standards of care and service delivery
• Be responsible for exploring current practice, identifying areas for development and planning the appropriate change using current evidence to evaluate outcomes
• Play a key operational role and maintain a proactive approach to managing patient flow
• Ensure that patients and their families are fully informed and supported by providing clinical and social support
• Assist in the development of evidence based clinical practice in line with current research and guidelines
• Establish clear lines of communication within the speciality team to ensure cohesive multidisciplinary management of patients
• Line with healthcare teams in order to increase knowledge and facilitate the care of this group of patients in the community

Sutton Health and Care (SHC) is an exciting and innovative health and care partnership that provides community health and sexual health services to local people in Sutton.

SHC is a commitment by partners to work differently in Sutton. We work to remove organisational boundaries in order to accomplish more for the people we care for. This enables us to deliver services with a strong focus on self-care, health promotion and prevention, allowing people to have a choice and control over the way their care is planned and delivered. By working together to share resources and information, we can better improve the health and wellbeing of the local community and importantly, tackle health inequalities across the borough.

We pride ourselves in having a highly dedicated team and offer a stimulating and dynamic working environment with a wide range of staff benefits and development opportunities. We are looking for employees who aspire to excellence, share our vision and values and can play a crucial role in our ongoing achievements.

Clinical Practice

• To assist in leading the delivery of services for older people in the Housing with Care residences in Sutton
• To be skilled in independent clinical assessment of older people presenting to hospital acutely
• Be recognised as experts in their field holding additional qualifications/specialist knowledge and expertise
• To maintain clinical credibility by acting regularly as a clinical practitioner
• To provide specialist nursing/therapy advice and support to patients, their families and other healthcare professionals regarding admission avoidance and care planning
• To ensure continuity of a high standard of evidence-based care, assessing health, health related and nursing needs of patients, their families and other carers by identifying and initiative appropriate steps for effective care

This can include

• Coordinating the multi-disciplinary assessment of patients, providing detailed baseline patient assessment, education and support to patients and their families
• Facilitating comprehensive geriatric assessment of patients
• Being actively involved in patient care, liaising with Primary Care, adult Social Care, Community Services and services including Virtual Ward to ensure high quality clinical care
• Liaising with the discharge lead and the At Home Team and wards to ensure appropriate, safe and timely discharge/follow up arrangements are in place
• Acting as an interface between the Service Manager and the CHST for Older People and Learning Disabilities to ensure appropriate escalation/update occurs regarding key clinical and managerial issues
• Actively involving service users in providing feedback of their experience and suggestions for improvements
• Working in line with and contributing to local delivery of national care standards
• Being highly visible and proactive acting as a clinical resource and ensuring the sustained delivery of high standards of nursing care
• Be responsible for exploring current practice, identifying areas for development and planning the appropriate change using current evidence to evaluate outcomes
• Delivering successful engagement and implementation within all areas of responsibility to support initiatives to improve nutrition and hydration
• Having expert knowledge in safeguarding processes and supporting the MDT in decision making
• Practicing as an independent prescriber within scope of practice
• Supervising and participating in the delivery of programmes of education/training according to the identified needs to the clients, carers and others
• Contributing to the development of clinical practice within the team
• Attending meetings/conferences as appropriate
• Promoting and facilitating evidence based practice and clinical audit within the Trust
• Participating in and assisting with any appropriate/relevant Trust approved research projects
• Utilising up to date research/evidence to deliver patient care and to disseminate this knowledge to all members of the MDT
• Promoting clinical research and evidenced based practice relevant to the role
• Provide training for health and social care staff
• Have students of all disciplines allocated whilst they are on their training placement
• Act as a supervisor/assessor for student nurses/AHPs on placement

Management

• To liaise effectively with all other disciplines within the Trust and at local level
• Deputise for Clinical Lead/Service Manager
• Act as e-rostering approver
• Participate in the management of change to improve standards and communication links from Primary to Secondary and Tertiary Care
• Attend Joint Intelligence Group meetings as requested
• Utilise and maintain information systems to aid audit and provide regular activity analysis reports
• Maintain contemporaneous and accurate treatment records, submitting relevant statistics, reports and activity data as requested
• Ensure the best use of available resources is used with agreed budget to provide a cost effective service

Personal and Professional Development

• Achieve a range of clinical competencies as required to fulfil role
• Keep up-to-date with current literature and research in the speciality
• Maintain own personal and professional development requirements
• Undergo and actively participate in own performance appraisals
• Work towards higher degree or equivalent

General

• Have responsibility for the health, safety and welfare of self and others
• Ensure confidentiality at all times
• Work in accordance with Trust Guidelines and Protocols
• Ensure skills are up-to-date and relevant to the role