Frailty Matron/Nurse

Job summary At Rosebank Health, we are committed to providingexceptional care to our patients, with a particular focus on supporting thoseliving with frailty.
We are seeking a dedicated and experienced Frailty Matronto join our team and lead the delivery of high-quality care for our frailpatients.As a Frailty Matron, you will play a pivotal role inmanaging and coordinating care for patients with frailty.
You will work closelywith our multidisciplinary team to ensure that our patients receivecomprehensive, person-centred care that meets their individual needs.
With a caring and compassionate outlook, you will beresponsible for delivering effective comprehensive geriatric assessments,compiling Care Plans, managing acute illness and supporting patients dischargedfrom secondary care.Applications are invited from experienced HealthcarePractitioners who can demonstrate enthusiasm and a clear patient centredapproach to promoting independence and wellbeing.Although based at Kingsway Heath Centre, your role willinvolve meeting patients in their own homes, care homes, and working from ourother three practices.A current driving licence and vehicle will be required.
Main duties of the job Job Purpose Towork as an autonomous practitioner providing expert clinical case management forpeople with frailty with intensive, chronic, transitory and acute,biopsychosocial needs and who are at risk of increased loss of independencethat may result in loss of quality of life, avoidable hospital admission orunnecessary length of hospital stay.
The FrailtyMatron will be responsible for a caseload of people who have been identified bythe GP or others as needing support to improve or maintain their quality oflife.
The Frailty Matron will work closely with the GP to manage the needs ofpeople with moderate and severe frailty.
Thepost holder will be expected to develop & maintain knowledge and skills infrailty, physical assessment and clinical reasoning, diagnostic reasoning andindependentprescribing.
Using these skills will assist in therecognition of early symptoms of frailty, disease exacerbation, acute illnessand injuries.
Thepost holder is not currently be required to work weekends or bank holidaysalthough this may change in the future.
About us Rosebank Health is a forward thinking practice operating over four sites, serving a population of over 40000 patients in Gloucester.
We are a well established training practice for GP trainees, nursing students and other health professionals.
The Partners work in close collaboration with the clinical team, practice management and administrative support team to work towards a patient centered vision for the practice.We are committed to providing an open, friendly and supportive environment where all staff are comfortable sharing ideas and can expect to be provided with the tools and support they need to enjoy work and succeed in their role.
We will provide the ongoing coaching and development you'll need to be a confident Frailty Matron, hopefully leading to a long and successful career in Primary Care.
Job description Job responsibilities To provide expert clinical case management for people with frailtywho may have multiple long-term conditions and are at risk of deterioratinghealth that may result in declining clinical quality of life or avoidablehospital admission, or unnecessary length of hospital stay.
Developrelationships with staff within the PCN, ICT, Complex Care at Home, IntegratedCare Hub, Older Peoples Mental Health service, Rapid Response, adult social care,and the voluntary sector collaborating with them on a day-to-day basis.
Undertakecomprehensive assessment of the physical and psycho-social care needs of peoplewith frailty who may also have complex chronic disease.
This will involve usinga single assessment process, gathering, and interpreting information, carryingout and ordering investigations and analysing the results alongside and withthe support of GP colleagues.
Establish anindividuals functional capabilities with regard to frailty as well as any long-termconditions clinical management.
Develop a personled evidence-based holistic health and social care plan in conjunction withmedical and other health and social care colleagues, in partnership withpatients and their relatives.
Workcollaboratively with colleagues and use the eFI/Rookwood frailty scoring systemas well as the proactive whiteboard to actively seek out patients; identifyingthe early symptoms of frailty, disease exacerbation, acute illness, andinjuries or who will benefit from clinical case management techniques to avoidunplanned hospital admission and reduce the length of hospital stays.
Review patientswith moderate to severe frailty who may be acutely unwell or whose conditionmay be deteriorating and formulate a management plan.
Work autonomouslyto prioritise individuals for assessment and management according to theirhealth status and needs, referring for specialist assessment, diagnostic testsand programmes of support as appropriate.
Demonstrate a high level of clinicaljudgement.
Facilitatedischarge from hospital by co-ordinating care and services to be deliveredwithin primary care, working in partnership with hospital ward staff, theintegrated care team and other appropriate agencies, including the voluntarysector.
Initiate and leadmedicine management, reviews of medication and prescribe/deprescribe medicinesand appliances for people via independent and supplementary prescribingarrangements.
Establish andmaintain excellent communication with individuals and groups, exploring complexissues relating to care options and decisions and sustain effective workingrelationships across all health and social care service organisations.
Use a high levelof communication and interpersonal skills to support and communicateeffectively with patients, families and carers.
Refer individualsto mental health and/or other services where appropriate.
Enable individualsto access psychological support.
Work proactivelywith people with frailty and their families to plan for and improve end of lifecare, ensuring that choices are reflected in personalised care plans andcommunicate with others involved in their care.
Ensure patients needingpalliative care are aligned to theGloucestershire End of Life Strategy and NICE Clinical Guidelines.
Challengeprejudice and inequalities in access to mainstream provision for individualswith frailty and may have long term conditions.
Interpret anddiscuss assessment outcomes with people, carers, their GPs and other health andsocial care professions and the voluntary sector.
Enable people tobe as independent as possible by facilitating a range of self-managementstrategies through undertaking desired occupations and non- occupational activitiesincluding the support that is available from the voluntary sector.
Be responsible forthe co-ordination of weekly/fortnightly MDTs in each GP practice.
Utilise knowledgeand experience of Expert Patient Programmes and Self-Management Programmes toenhance both an individuals care pathway and the quality of service provided.
Monitor qualityand effectiveness of clinical care for people with frailty through audit andresearch.
Acceptresponsibility for teaching professional colleagues, nursing auxiliaries,student nurses, people and carers.
To fulfil therequirements for maintaining a professional registration.
The post holder isexpected to adhere to local policy and procedures.ConfidentialityIn the course ofseeking treatment, Rosebank Health patients entrust us with, or allow us togather, sensitive information in relation to their health and other matters.
They do so in confidence and have the rightto expect that staff will respect their privacy and act appropriately.In the performanceof the duties outlined in this job description, the post-holder may have accessto confidential information relating to patients and their carers, practicestaff and other healthcare workers.
Theymay also have access to information relating to the practice as a businessorganisation.
All such information fromany source is to be regarded as confidential.Informationrelating to patients, carers, colleagues, healthcare workers or the business ofthe practice may only be divulged to authorised persons, in accordance withpractice policies and procedures relating to confidentiality and the protectionof personal and sensitive data.Health & safetyUsing personalsecurity systems within the workplace according to practice guidelines.Practice andconduct themselves in such a manner as to promote a safe and efficient workingenvironment.
Identify andescalate any risks or safeguarding concerns to senior colleagues and activelyseek to reduce or eliminate those concerns identified in a positive manner.
Implement anydirectives from senior colleagues which seek to promote staff safety or reduceorganisational risk.
Embracesafeguarding mechanisms and support staff, patients and families during such astime when safeguarding principles may be applied.
Equality and diversityThe post-holderwill support the equality, diversity and rights of patients, carers and colleaguesby:Acting in a waythat recognizes the importance of peoples rights, interpreting them in a waythat is consistent with practice procedures and policies, and currentlegislationRespecting theprivacy, dignity, needs and beliefs of patients, carers and colleaguesBehaving in amanner which is welcoming to and of the individual, is non-judgmental andrespects their circumstances, feelings priorities and rights.Personal/Professional DevelopmentThe post-holderwill participate in any training programme implemented by the practice as partof this employment, such training to include:Participation in anannual individual performance review, including taking responsibility formaintaining a record of own personal and/or professional development.Takingresponsibility for own development, learning and performance and demonstratingskills and activities to others who are undertaking similar work.Encouragement todevelop and keep up to date with new services within the NHS.QualityThe post-holderwill strive to maintain quality within the practice, and will:Alert other teammembers to issues of quality and risk.Assess ownperformance and take accountability for own actions, either directly or undersupervision.Contribute to theeffectiveness of the team by reflecting on own and team activities and makingsuggestions on ways to improve and enhance the teams performance.Work effectivelywith individuals in other agencies to meet patients needs.Effectively manageown time, workload and resources.CommunicationThe post-holder should recognize the importance of effectivecommunication within the team and will strive to:Communicateeffectively with other team membersCommunicateeffectively with patients and carersRecognize peoplesneeds for alternative methods of communication and respond accordinglyContribution to the implementation of servicesThe post-holder will:Apply practicepolicies, standards and guidance.Discuss with othermembers of the team how the policies, standards and guidelines will affect ownwork.Participate inaudit where appropriate.Safeguarding Rosebank Health is committed tocreating and maintaining a safe and supportive environment for all individualsinvolved in our Practice.
Safeguarding is a fundamental aspect of ourorganisation, and we prioritise the well-being and protection of children, youngpeople, vulnerable adults, and all those who may be at risk of harm.
As part of our commitment tosafeguarding, all employees, volunteers, and contractors are expected to sharethis commitment and adhere to the Practices safeguarding policies and procedures.We strive to ensure that everyone associated with Rosebank Health understandstheir responsibility to identify and report any safeguarding concerns promptly.
Person Specification Knowledge Essential Highly specialist knowledge in managing patients in the community with complex medical needs, long term/ chronic disease management and palliative care Highly developed professional knowledge base, supported by educational development and different work environments.
Good organisational skills and methodical approach to managing a workload Conscientious and able to prioritise work and work to deadlines Ability to communicate effectively, both verbally and in writing Ability to maintain effective working relationships and to promote collaborative practice with all colleagues Ability to demonstrate personal accountability, emotional resilience and work well under pressure Desirable Knowledge of current and emerging health and social care economy specifically the social care agenda Specialist knowledge of governance and risk strategies and their application in a community setting Able to work across organisations and with a wide range of Health Care Professionals Qualifications Essential Current registered Nurse (NMC) Advanced Physical Assessment & Clinical Reasoning - or willingness to work towards Advanced Diagnostic Reasoning for Advancing Practice Independent Non-medical Prescriber or willingness to work towards Desirable Acute/Long term conditions management qualification Relevant MSc Experience Essential Experience as an autonomous practitioner within primary care or frailty service Desirable Knowledge/experience of SystmOne