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Frailty Nurse for Housing with Extra Care

Epsom and St Helier University Hospitals NHS Trust
£49,178 to £55,492 a year pro rata incl outer London HCAS
Closing date
4 Jun 2024

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Nurse, Adult nurse, Elderly care nurse
Band 7
Contract Type
Part Time
Thank you for taking the time to consider this opportunity to work with Sutton Health and Care. We are firmly committed to being the best possible provider of community healthcare and place to work in the NHS and we have an exciting opportunity to recruit a Band 7 Frailty Nurse to work with our Care Home Support Team for Housing with Extra Care.

Main duties of the job

The role will be to
  • Perform independent clinical assessments of frail older adults and recommend appropriate care strategies
  • Be highly visible and proacting acting as a clinical resource and ensuring the sustained delivery of high standards of care and service
  • 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 specialty team to ensure cohesive multidisciplinary management of patients
  • Link with healthcare teams in order to increase knowledge and facilitate the care of this group of people in the community
  • Support the prevention of unplanned hospital admissions and respond to patients who require urgent assessments, and set up management plans to enable the patient to stay at home if possible.

About us

Epsom and St. Helier University Hospitals NHS Trust (ESTH) provides a range of medical services to approximately 500,000 people living across south west London and north east Surrey. We serve an area that is rich in diversity, with a mix of urban and rural areas and differing levels of quality of life. Together with our colleagues in NHS Surrey and NHS Sutton and Merton we work to make sure that we deliver the best possible care to the communities we service.

Sutton Health and Care (SHC) is an innovative joint venture between local partner health and social care organisations, which sees community services fully integrated to support the delivery of a new model of care for the people of Sutton. Hosted by ESTH, the model ensures the breaking down of traditional organisational barriers to enable the provision of care that is wrapped around the patient.

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.

Job description

Job responsibilities

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 for older people presenting to hospital acutely
  • 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 high standards 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
  • To regularly review patient care pathways with colleagues preventing duplication of work and promoting service efficiency
  • Work with colleagues to lead on development, implementation and evaluation of protocols, policies and integrated care pathways
  • Coordinating the multidisciplinary assessment of patients, providing detailed baseline patient assessment and education and to support to patients and their carers
  • Facilitating comprehensive geriatric assessment of patients
  • Being actively involved in patient care, liaising with Primary Care, Adult Social Care, Community Services colleagues to ensure high quality clinical care
  • Liaising with the discharge lead and the At Home team to ensure appropriate, safe and timely discharge/follow up arrangements are in place
  • Acting as an interface between the Service Operational Manager and the CHST for older people and learning disabilities to ensure appropriate escalation/updates occur regarding key clinical/managerial issues affecting the service
  • Liaising with local community, social services, paramedics and voluntary organisations in order to develop existing services for clients
  • Actively involving service users in providing feedback of their experience
  • Working in line with and contributing to local delivery of national care standards
  • Being a highly visible and proactive leader acting as a clinical resource
  • Being responsible for exploring current practice, identifying areas for development and planning the appropriate change to evaluate outcomes
  • Delivering successful engagement and implementation within all areas of responsibility to support initiatives to improve nutrition, hydration, privacy and dignity
  • Having knowledge of safeguarding processes and supporting the MDT in decision making
  • Enabling patients to plan for unavoidable progression of their conditions
  • Having comprehensive and effective use of communication skills including communication of highly sensitive and completion information to patients regarding their condition
  • In collaboration with community nursing colleagues, regularly attend MDT meetings to ensure representation from the service.

Education and Research
  • Supervising and participating in the delivery of programmes of education and training according to identified needs
  • Contributing to the development of clinical practice within the team
  • Actively participating in educational events
  • Attending meetings/conferences as appropriate
  • Promoting and facilitating evidence based practice and clinical audit and informing business/service development plans
  • Participating in and assisting with any appropriate/reelvant Trust approved research projects
  • Utilising up to date research/evidence to deliver patient care and disseminate knowledge to all members of the MDT
  • Promoting clinical research and evidence based practice relevant to the role
  • Work with the MDT to coordinate development implementation and evaluation of teaching programmes.

  • Liaise effectively with all other disciplines within the Trust and at local level
  • Attend Joint Intelligence Group meetings when required
  • Utilise and maintain information systems to aid audit and provide regular activity reports
  • Maintain contemporaneous and accurate treatment records
  • Ensure the best use of available resources within agreed budget

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 specialty
  • Maintain own personal and professional development requirements
  • Undergo and actively participate in own performance appraisals
  • Keep up to date with relevant specialist Faculty and Trust guidelines/protocols
  • Adhere to the Code of Professional Conduct

  • To have responsibility for the health, safety and welfare of self and others
  • To maintain confidentiality
  • To work in accordance with the Trust's Equal Opportunities policy
  • To ensure skills are up to date and relevant to the role
  • To comply with the Trust's policies and guidelines
  • To participate in surveys and audits as necessary in order to improve patient outcomes.

Person Specification

Education and Qualifications


  • Full NMC Registration and current revalidation
  • Degree in relevant subject
  • Recognised teaching and assessment qualification
  • Dementia training
  • In depth knowledge of frailty
  • Community Nursing/Advanced Nurse/Clinical Practitioner qualification


  • Community nursing/Advanced Nurse/Clinical Practitioner qualification
  • Relevant Masters level degree
  • Trained to interpret microbiology and pathology results
  • Non medical prescriber/supplementary prescribing or willingness to undertake training within 12 months of coming into post



  • Experience of working as an autonomous practitioner
  • Case management experience
  • Good understanding of working in partnership with statutory/non statutory patient centred care
  • MDT and multi agency working experience
  • Proven extensive experience of working with adults/older people with frailty


  • Experience in a community setting
  • Experience of working between other health and social care organisations/settings
  • Ability to interpret blood results
  • Experience of IT systems in particular MS Office



  • Ability to demonstrate effective leadership and organisational skills
  • Clinical decision making skills to support patient centred care
  • Advanced physical assessment skills
  • Good knowledge of anatomy and physiology
  • Up to date working knowledge of both local and national policy issues pertinent to adults with long term conditions
  • Ability to communicate complex patient presentations to medical colleagues
  • Ability to direct and coordinate complex programmes of care working autonomously and collaboratively
  • Ability to communicate effectively in a variety of settings across organisational boundaries and within general public
  • Ability to work in a changing stressful situation
  • Ability to adapt to working in challenging environments to manage complex patient centred care


  • Knowledge relating to long term conditions
  • Ability to influence and manage a variety of change management programmes

Personal Attributes


  • Ability to remain calm under pressure
  • Ability to make informed and measured clinical decisions in all circumstances
  • Ability to manage conflicting priorities
  • Commitment to continuing professional and personal development
  • Enthusiastic and self motivated
  • Full driving licence and/or access to own transport to ensure travel across the borough to include personal and care homes

Employer details

Employer name

Epsom and St Helier University Hospitals NHS Trust


Green Wrythe Lane Health Clinic

Green Wrythe Lane



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