Job description

Job responsibilities

Job Purpose

To work as an autonomous registered nurse within the Frailty & Community Outreach Team, undertaking holistic assessment, clinical intervention and ongoing management of patients within their own homes.

The post holder will manage an allocated referral-based caseload and contribute to the delivery of annual long-term condition reviews for housebound patients. They will work closely with the Community Specialist Nurse and wider health and care professionals to provide safe, personalised and preventative care.

The post holder will:

• Undertake autonomous holistic assessment of patients within their own homes.
• Apply Comprehensive Geriatric Assessment (CGA) principles where clinically appropriate.
• Undertake physical assessment, clinical observations and examination within professional competence.
• Assess frailty, function, falls risk, cognition, psychological wellbeing and social circumstances.
• Use clinical reasoning to identify priorities and develop personalised plans of care.
• Recognise deterioration and initiate appropriate treatment, escalation or onward referral.
• Support patients with multimorbidity and long-term conditions, including annual health reviews for the housebound cohort.
• Review medication as part of holistic assessment, identifying adherence, safety or optimisation concerns and liaising with prescribers or pharmacy colleagues as required.
• Support advance and future care planning where appropriate.
• Promote independence, self-management and prevention of avoidable deterioration.

• Recognise and assess mental health and psychological needs alongside physical health needs.
• Work confidently with patients with established mental health diagnoses or psychological distress.
• Understand how neurodivergence, substance use, self-neglect and wider psychosocial circumstances may affect health, behaviour and engagement with services.
• Recognise mental health deterioration and risk and escalate appropriately.
• Develop effective therapeutic relationships with patients who may experience difficulty accessing or engaging with conventional healthcare.
• Work collaboratively with primary care and specialist mental health services where appropriate.

• Identify and respond appropriately to safeguarding concerns and self-neglect.
• Apply the Mental Capacity Act in clinical practice and undertake decision-specific mental capacity assessments within professional competence.
• Contribute to best-interests decision-making where required.
• Assess and manage clinical and environmental risk proportionately, balancing safety with patient autonomy.
• Escalate significant clinical, safeguarding or professional concerns appropriately.

• Manage and prioritise an allocated caseload autonomously.
• Plan appropriate follow-up and review according to individual patient need.
• Coordinate care across primary care, community health, mental health, social care and voluntary-sector services.
• Liaise effectively with patients, families, carers and professionals.
• Participate in multidisciplinary discussion where this would benefit an individual patient's care.
• Ensure appropriate transfer or discharge when active team involvement is no longer required.

• Maintain accurate and contemporaneous clinical records.
• Work in accordance with the NMC Code, evidence-based practice and organisational policies.
• Recognise the limits of own competence and seek senior or specialist advice when required.
• Provide clinical support and guidance to less experienced colleagues, nursing associates, support workers and students as appropriate.
• Participate in clinical supervision, audit, quality improvement and service development.
• Maintain professional competence and continuing professional development.
• Contribute positively to multidisciplinary team working and the ongoing development of the Frailty & Community Outreach Team.

Person Specification

Experience

Essential

• - Significant post-registration nursing experience.
• - Experience working autonomously and making clinical decisions within own scope of practice.
• - Experience undertaking holistic assessment of adults with multiple and interacting health needs.
• - Experience caring for people with frailty, multimorbidity and/or long-term conditions.
• - Experience recognising clinical deterioration and initiating appropriate escalation or onward referral.
• - Experience supporting people with mental health needs alongside physical health needs.
• - Experience working with people who may have difficulty accessing or engaging with healthcare services.
• - Experience identifying and responding to safeguarding concerns, including self-neglect.
• - Experience applying the Mental Capacity Act in clinical practice.
• - Experience managing and prioritising a clinical caseload.
• - Experience working across professional and organisational boundaries as part of multidisciplinary care.

Desirable

• - Experience working in primary care, community nursing, frailty, outreach or a similar community-based service.
• - Experience applying Comprehensive Geriatric Assessment (CGA) principles.
• - Experience working with people with significant mental health or psychosocial complexity, including substance use, neurodivergence or self-neglect.
• - Experience undertaking cognitive or memory assessments.
• - Experience undertaking long-term condition reviews.
• - Experience of advance care planning and ReSPECT.
• - Experience supporting or supervising students, nursing associates or less experienced staff.
• - Experience contributing to audit, quality improvement or service development.

Additional Requirements

Essential

• - Full UK driving license and access to car for work purposes
• - Applicants must have the right to work in the UK. Unfortunately, we are unable to offer visa sponsorship for this role.

Qualifications

Essential

• - Registered Nurse with current NMC registration.

Desirable

• - Relevant post-registration education or training in clinical assessment, frailty, long-term conditions or community nursing.
• - Competent in venepuncture/phlebotomy, or willing to undertake training and competency assessment.
• - Training or competency in physical assessment and clinical examination.

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.

UK Registration

Applicants must have current UK professional registration. For further information please see NHS Careers website (opens in a new window).

Employer details

Employer name

East and Central Brighton Primary Care Network

Address

East and Central Brighton PCN

4th Floor Freedom Works, Barts House

Black Lion Street

Brighton

East Sussex

BN1 1ND

United Kingdom