Frailty Nurse - Adult Community Nursing 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.

Main duties of the job

• 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.
• This is a key role within the multidisciplinary team, delivering proactive, safe, and coordinated care for those living with frailty.
• Provide leadership and education, train staff and students, and help deliver optimum nursing care.
• Use specialist skills to assess, plan, implement, and evaluate expert 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.
• Work autonomously to manage a personal caseload while contributing as part of the Community of Practice Multi-disciplinary Team.

About us

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. We offer opportunities across medical, clinical, support, and corporate services.

Why work for us?

• Positive 2024 NHS Staff Survey results, highlighting compassionate leadership and wellbeing.
• Varied environments: community hospitals, patients' homes, and bases across Sussex.
• Flexible working options: part-time, flexi-time, annualised hours, and flexi-retirement.
• Excellent training, development, and research opportunities.
• Accredited Living Wage Employer, we ensure fair pay for all our staff.
• Cost-effective workplace nurseries in Crawley, Hove, and Brighton.
• Active EMBRACE, Disability & Wellbeing, LGBTQIA+, and Religion & Belief networks.
• Level 3 Disability Confident Leader and Veteran Aware Trust.

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.

Job responsibilities

• Is wholly accountable for his/her practice and takes every available opportunity to sustain and improve knowledge and professional competence.
• Working autonomously to manage his/her own caseload of patients, whilst working as part of the Community of Practice Multi-disciplinary team; providing a high quality specialist nursing service for patients with frailty.
• Provide expert clinical advice in accordance with current evidence based practice.
• Use advanced nursing skills to assess, plan, implement and evaluate physical and psychosocial needs of those living with frailty, instigating treatment based on best available evidence in order to stabilise the individuals condition, prevent admission and maintain independence appropriate to that person.
• To agree a personal management plan with the patient, ideally with inclusion of carers, relatives and other appropriate health care professionals.
• This will be based on a full assessment of medical, nursing and basic social care needs.
• To use advanced nursing skills and expert knowledge to identify changes in the patients condition, analysing and interpreting complex health problems and associated scenarios.
• To work with patients to identify problems from their perspective and develop holistic management plans.
• To negotiate and agree with clients, carers, community nurse teams and other care professionals, individual roles and responsibilities with actions to be taken and outcomes to be achieved, referring on to other services or professionals as appropriate.
• To work across professional and organisational boundaries, identifying areas for skill and knowledge development applying these to individual practice with the aim of providing continuity and high quality patient centred care.
• To enable clients and carers to manage their medications in conjunction with GPs, pharmacists and other relevant clinical staff, including medication reviews as part of initial assessments and ongoing patient reviews.
• To provide expert clinical care and health promotion.
• To support the Deputy Head of Service in the management of serious incidents and root cause analysis, sharing learning outcomes and best practice with clinical staff.
• Use expert knowledge and skills as a non-medical prescriber to independently prescribe within the individual practitioners areas of prescribing competency.
• Develop prescribing clinical management plans as appropriate in partnership with Geriatricians/GP colleagues.
• Work to the NMC code of practice and maintain professional registration.
• To anticipate medical, care and social support needs of those living with frailty.

Person Specification

Skills and Knowledge

• Able to analyse complex situations and problem solve as necessary.
• Evidence of ability to identify and manage risk.
• Evidence of knowledge and experience of team dynamics/leadership role.
• Evidence of ability to work in a multi-disciplinary team.
• Evidence of embracing change and implementing change to provide high quality health care.
• Ability to work in a flexible way and respond positively to change.
• Ability to work autonomously and make own decisions.
• Understanding of Clinical Governance.
• Understanding of local and national policies.
• Acknowledges limitations to practice.
• Awareness of own development needs.
• Evidence of long term condition management.
• Evidence of complex care management.
• Awareness of resilience.

Other Requirements

• Care driver with access to a vehicle for work purposes.

Qualifications

• RN first level nurse.
• Post graduate level degree or equivalent.
• Advanced Physical Assessment course Master Module.
• Non medical prescriber or willing to work towards.
• Mentoring course or equivalent/Practice Assessor.
• Community specialist practice qualifications (District Nurse) or equivalent qualification.

Desirable

• Masters qualifications.
• Public Health Module or willing to work towards.

Experience

• Advanced Physical Assessment.
• Independent or supplementary prescribing medication review and administration.
• Evidence or ability to direct and co-ordinate programmes or care working autonomously and collaboratively.
• Able to analyse complex situations and problem solve as necessary.
• Evidence of the ability to identify and manage risk.
• Evidence of knowledge and experience of team dynamics/leadership role.
• Evidence of knowledge and experience of working between acute and primary care settings.
• Evidence of ability to work with a multidisciplinary team.
• Evidence of working in partnership and collaboration with other professionals.
• Evidence of effective organisational skills.
• Evidence of embracing and implementing change to provide high quality health outcomes.
• Evidence of the ability to champion patient issues.
• Evidence of the ability to work in a changing and sometimes stressful situation.
• Ability to appropriately challenge a variety of professionals about an individuals care.
• Ability to resolve or diffuse conflict.
• Evidence of ability to identify training needs.
• Evidence of using one to one mentoring skills.
• Evidence of teaching patients and carers.
• Evidence of communication skills.
• Assertiveness and able to negotiate in complex situations.
• IT and ability to use Microsoft suite.
• Ability to work in a flexible way and respond positively to change.
• Ability to work autonomously and make own decisions.
• Demonstrate a high level of understanding of self and able to identify personal limitation and show openness to address them.

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.

Applications from job seekers who require current Skilled worker sponsorship to work in the UK are welcome and will be considered alongside all other applications. For further information visit the UK Visas and Immigration website.

Applicants must have current UK professional registration.