Community Frailty Nurse

We are seeking a motivated individual with a solution focused approach to work as a Nurse as part of the Community Frailty Hub. This key role is vital in providing comprehensive care coordination to patients living with Frailty. This is a full-time role but part-time applications will be considered. The Community Frailty Nurse will work as part of the Community Frailty Hub's multidisciplinary team to provide high-quality, person‑centred care to older adults living with frailty in the community. The post holder will assess, plan, implement, and evaluate care needs, promoting independence and improving quality of life.

This role involves close collaboration with GPs, social services, allied health professionals, and voluntary sector partners. In this busy challenging role, you will be able to work on your own initiative, be comfortable in making decisions within the scope of your practice whilst demonstrating an understanding of community services and using the guidance and support of the multidisciplinary team. You will require use of your own car and a driving license. Hours are 7 days a week - This includes evenings, weekends and Bank Holidays on a rota basis. Interviews are expected to be held in-person in York. Please note: We anticipate a high volume of applications for this role and therefore encourage early submissions. We reserve the right to close this advert ahead of the published deadline if sufficient applications are received and interviews are scheduled.

Main duties of the job

• Using a Comprehensive Geriatric Assessment you will plan, implement and evaluate care for our patients in the community.
• Act as Care Coordinator for a cohort of patients, to meet patients' needs and preferences in the delivery of high‑quality, high-value health care.
• Ensure that the patient's needs and preferences are known and communicated at the right time to the right people, and that this information is used to guide the delivery of safe, appropriate, and effective care.
• Coordinate continuity of patient care with external organisations, including hospital admission and discharge and referrals from the primary care provider to a specialty care provider.
• Provide advice and guidance to junior staff.
• Work across various healthcare settings, including surgeries, home visits, and community.
• Offer on‑call telephone support on a rota basis.
• Mentor and train junior and healthcare support staff.
• Facilitate patient education, self‑management of disease, and behaviour modification.
• Ensure continuity of care, particularly during transitions like hospital admission and discharge.
• Manage complex patients in their homes, collaborating with multidisciplinary teams.
• Promote clear communication with the health care team and support medication management.
• Participate in team meetings, audits, and data collection for improving patient care.
• Ensure compliance with CQC requirements and maintaining accurate documentation.

About us

Nimbuscare is a not‑for‑profit Organisation that aims to be a collaborative and agile provider that cares for its people and patients. Nimbuscare is based in York and is owned by all the practices in the city. We deliver Urgent Care services in collaboration with the hospital and GP practices across North Yorkshire. We also provide community‑based frailty care. We aim to shift services into the community where possible, for example, our community diagnostic centres run in partnership with the Acute Trust. We are committed to contributing towards a better NHS based on equity, fairness, innovation, collaboration and quality. Nimbuscare is committed to improving the diversity of its workforce to better reflect the communities we serve. We welcome applications from everyone and work to promote an inclusive supportive culture that values and celebrates our differences. As a Disability Confident Committed employer, disabled applicants who meet the essential criteria for this job are guaranteed an interview.

Job responsibilities

• Deliver holistic nursing assessments and contribute to comprehensive geriatric assessments (CGA) in the community.
• Develop, implement, and review personalised care plans that meet the physical, emotional, and social needs of frail older adults.
• Identify early signs of deterioration and implement proactive interventions to avoid hospital admissions where appropriate.
• Promote self‑management and independence for patients living with Frailty.
• Work collaboratively with the wider multidisciplinary team, including GPs, therapists, social workers, and support workers.
• Support discharge planning and transitional care from acute settings back into the community.
• Provide health education to patients, families, and carers.
• Support in advanced care planning conversations where appropriate.
• Maintain accurate and timely clinical records in accordance with local policies and NMC standards.
• Participate in clinical supervision, audits, and service development initiatives.
• Provide support to our Health Support Workers as and when needed.

Business responsibilities

• Maintain ethos and culture of Nimbuscare Limited.
• Positively promote Nimbuscare Limited both in and out of the workplace.
• Attend educational and staff meetings as requested.
• Support the introduction of new working processes to optimise quality.
• Build and maintain relationships with relevant personnel.

Learning and development

• Participate in any training programme implemented by Nimbuscare Limited as part of this employment, such training to include:
• Participation in individual performance reviews, including maintaining a record of own personal and/or professional development.
• Make effective use of learning opportunities within and outside the workplace.
• Undertake mandatory and statutory training as required.
• Work as an effective and responsible team member, supporting others and exploring the mechanisms to develop new ways of working.
• Accept delegation from senior staff, prioritise own workload and ensure effective time management strategies are embedded in own practice.
• Participate in team activities that create opportunities to improve patient care.
• Contribute to the effectiveness of the team by reflecting on own and team activities and making suggestions on ways to improve and enhance the team's performance.

Confidentiality

To understand and be aware of the confidentiality of information gained during your duties, which may include access to personal information relating to clients, patients and members of staff. It is expected that you understand the importance of treating information in a discreet and confidential manner.

Health & Safety

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.

Equality and Diversity

To actively support equality, diversity and inclusion and ensure that all work colleagues, patients and staff are valued and treated with dignity and respect.

Quality

Alert other team members to issues of quality and risk. Assess own performance and take accountability for own actions, either directly or under supervision. Effectively manage own time, workload and resources. Work within own limitations and experience. Be aware of and co‑operate with audit. Work effectively with individuals in other agencies to meet patients' needs. Portray a professional image at all times.

Communication

Communicate effectively with colleagues, patients and external parties. Recognise and have awareness of people's needs for alternative methods of communication and respond accordingly.

This list of duties is not exhaustive.

Person Specification

Physical skills

• Use of own car and driving licence.

Capabilities and Attributes

• Team Work: Work effectively and professionally within the community frailty hub through willingness to proactively support and assist their peers and colleagues.
• Autonomous: Ability to work independently by making informed decisions based on professional knowledge and clinical judgement.
• Time & Workload Management: The ability to quickly react to and manage changing, unpredictable and fluctuating workloads using a variety of methods of communication. The ability to recognise when a problem/issue should be escalated or referred for specialist investigation because it falls outside of the scope of the role and your professional knowledge.
• Solution Focussed: Ability to react to and face challenges or setbacks in a positive manner with a commitment to continuous improvement of their own skills and behaviours and also of the service.
• Customer Service: Ability to remain focussed on providing and continuously improving an excellent internal customer service to the surgery team and clinical team(s).
• Deadline / Target Driven: Ability to work efficiently to strict deadlines and to be driven by the setting and achieving of individual and team targets.
• Confidentiality: Ability to exercise and adhere to the Practice confidentiality policies.
• Work Prioritisation: Ability to organise, prioritise and manage your own work demands by assessing levels of urgency and importance.

Qualifications

• Current NMC registration.

Skills and knowledge

• Communication Skills: Able to calmly, professionally and efficiently identify patients/internal customer needs. Able to professionally and efficiently deliver patients/internal customer needs with a warm reassuring demeanour. Able to skilfully signpost/refer the patient to the most appropriate person or alternative solution to their needs.
• IT Literate: Competent in the use of Microsoft Applications and a proven ability to learn how to navigate and interrogate systems, input data with an attention to detail and follow processes and procedures.

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.