Frailty Nurse - Adult Community Nursing | Sussex Community NHS Foundation Trust in Crowborough

This exciting post is available for a dynamic, holistic and forward thinking practitioner. The successful applicant will have the opportunity to work as an autonomous practitioner, and use their expert clinical frailty knowledge to assess, plan, implement, and evaluate expert nursing care.

The post holder will be expected to provide support to a group of patients with acute/intensive medical needs in the community setting, who are at risk of further deterioration in health that may result in avoidable hospital admission or unnecessary length of hospital stay. The post holder will work alongside patients and their families, GPs, community nursing teams and Frailty nurses in the High Weald Lewes and Havens area, and alongside Community Geriatricians offering specialist expert clinical advice in accordance with current evidence based practice. This is a temporary post to cover Maternity leave.

Key responsibilities include:

• Support the identification of Frailty using an agreed tool or through referrals from GPs or community professionals for patients needing intensive community support.
• Apply advanced nursing knowledge and skills, including independent prescribing, to identify changes in patient conditions, and analyse and interpret complex health scenarios.
• Deliver proactive, safe, and coordinated care for those living with frailty.
• Provide leadership and education, train staff and students, and help deliver optimum nursing care.
• Prevent unplanned hospital admissions through urgent assessment and planning of co-ordinated care with appropriate services to support patients at home or in suitable settings.
• Work collaboratively with primary care, community, and acute teams to ensure care is delivered in the most appropriate settings, reduce readmissions, and enable positive outcomes for frailty patients.
• Advocate for high-quality, consistent care programmes for individuals with frailty.
• Inform, teach, and mentor patients and families to help them understand and manage the impact of living with frailty.
• Manage a personal caseload while contributing as part of the Community of Practice Multi-disciplinary Team.

We are the main provider of NHS community services across East and West Sussex, with 6,000 staff serving 1.3 million people. We deliver essential care to adults and children, helping them manage their health, avoid hospital admissions, and reduce hospital stays. Our Trust vision is to provide excellent care at the heart of the community.

Our values—Compassionate Care, Working Together, Achieving Ambitions, Delivering Excellence—guide everything we do. We embrace diversity and encourage applications from all backgrounds, particularly from ethnically diverse, disabled, and LGBTQIA+ individuals. We aim to create an inclusive environment and support reasonable adjustments during recruitment.

This post may close early if sufficient applications are received. The post holder is wholly accountable for their practice and takes every available opportunity to sustain and improve knowledge and professional competence.

Responsibilities also include:

• Providing expert clinical advice in accordance with current evidence based practice.
• Using advanced nursing skills to assess, plan, implement and evaluate physical and psychosocial needs of those living with frailty.
• Agreeing a personal management plan with the patient, ideally with inclusion of carers, relatives and other appropriate health care professionals.
• Identifying changes in the patient’s condition, analysing and interpreting complex health problems and associated scenarios.
• Working with patients to identify problems from their perspective and develop holistic management plans.
• Negotiating and agreeing with clients, carers, community nurse teams and other care professionals, individual roles and responsibilities with actions to be taken and outcomes to be achieved.
• Enabling clients and carers to manage their medications in conjunction with GPs, pharmacists and other relevant clinical staff.
• Providing expert clinical care and health promotion.
• Supporting the Deputy Head of Service in the management of serious incidents and root cause analysis.
• Using expert knowledge and skills as a non-medical prescriber to independently prescribe within the individual practitioner's areas of prescribing competency.
• Developing prescribing clinical management plans as appropriate in partnership with Geriatricians/GP colleagues.
• Working to the NMC code of practice and maintaining professional registration.
• Anticipating medical, care and social support needs of those living with frailty.