Job summary Are you passionate about improving the lives of frail older adults? Join our new Community Frailty Ward as a Frailty Practitioner In this rewarding role, you will complete frailty assessments and manage complex care for frail patients. Your expertise in physical assessments, diagnostic reasoning, and polypharmacy management will help prevent unnecessary hospital admissions and prolonged stays. You will work with a multidisciplinary team to provide high-quality care across a 7 day service, supporting in the completion of Comprehensive Geriatric Assessments (CGA), and create treatment plans for patients facing crises or exacerbations of long-term conditions to prevent unwanted hospital admissions. You will also deliver frailty education to patients, families, and professionals. Key Responsibilities: Conduct frailty assessments and manage care for older adults with complex medical needs Provide advice to patients, families, and the MDT Address polypharmacy issues and conduct medication reviews Facilitate coordinated assessments and treatment plans Contribute to the Ageing Well MDT and support Livewell community teams What You will Bring: Expertise in frailty, CGA, and clinical reasoning Strong leadership and autonomy in a multidisciplinary team Ability to deliver education and empower others in frailty care Passion for improving patient outcomes and reducing hospital admissions Join us and make a lasting impact in community healthcare. We would love to hear from you Main duties of the job The Frailty Practitioner for the Frailty Virtual Ward will support the delivery of frailty education to colleagues, students & service users. You will lead people management tasks, including staff engagement, workforce planning, performance management, &training, with operational leads' support. As a clinical leader, you will complete CGA's, manage complex care plans &provide advice to the multidisciplinary team (MDT). Key responsibilities include managing referrals, ensuring case finding, initiating person-centred care plans &facilitating early discharge to prevent unnecessary hospital admissions. You will provide mentorship, supervision, appraisals &support practice supervision. Participation in service development, policy compliance, resource management &budget support are essential. You will collaborate with professionals to enhance care pathways, lead clinical audits &contribute to policy development. Strong communication skills are necessary for managing sensitive patient situations &fostering relationships with patients, carers, &professionals. Additionally, you will contribute to research, support safeguarding &engage in ongoing personal development. Additional duties include managing staff safety, adhering to infection control protocols &reducing environmental impact. This role requires a proactive, adaptable professional committed to high standards of care. please note that this role may not be eligible for sponsorship under the Skilled Worker route About us Livewell Southwest is an independent, award-winning social enterprise delivering integrated health and social care services across Plymouth, South Hams, and West Devon, with specialist services in parts of Devon and Cornwall. Our teams work in community hospitals, GP practices, sports centres, and health hubs. As an organisation with a strong social conscience we are guided by our values,kindness, respect, inclusivity, ambition, responsibility, and collaboration. We focus on transforming services to ensure sustainability, while empowering staff and those we serve. We involve the people we care for, along with their families and carers, in shaping the care they receive, striving to deliver the right care at the right time and place. Centering our work on individual needs helps people lead healthy, independent lives. We prioritise employees' development, offering protected CPD time, training pathways, leadership programs, and funding for qualifications like the Care Certificate and Nurse Training Scholarships. Our induction and preceptorship programs ensure a smooth transition into our organisation. Livewell Southwest values diversity and encourages applications from all sections of the community, including those with armed forces experience, lived experience of mental health, neuro-diverse conditions and learning disabilities. If you need assistance or reasonable adjustments during the application process, contact the Recruiting Manager listed in the job advert. Date posted 27 January 2025 Pay scheme Agenda for change Band Band 7 Salary £46,148 to £52,809 a year pro rata Contract Permanent Working pattern Full-time, Part-time, Job share, Flexible working Reference number B9832-2025-NM-9474-5 Job locations 200 Mount Gould Road Mount Gould Plymouth Devon PL4 7PY Job description Job responsibilities Job Title: Frailty Practitioner Band: Band 7 Locality: Adult Frailty and Specialist Services Base: Community Settings Responsible to: Integrated Operational Lead Job Purpose: The Frailty Practitioner leads on frailty care within community integrated teams. They use their expertise in physical and diagnostic assessments, medication reviews, and geriatric assessments (CGA) to help prevent hospital admissions and improve care for frail older adults. The role involves providing specialist advice, case management, and supporting multidisciplinary teams in comprehensive geriatric assessments. Departmental Position: The role reports to the Integrated Operational Lead for localities and works closely with various team leads in Adult Frailty and Specialist Services (AFSS). They play a key role in enhancing primary care and supporting service transformation for frailty services. Main Duties & Responsibilities: People Management: Plan and deliver frailty education programs for community team members, students, service users, and professionals. Manage staff tasks, including communication, appraisals, training, and performance management. Function as a clinical mentor and role model, supporting staff and students. Offer support in handling complaints and incidents, ensuring work is appropriately delegated to the multidisciplinary team (MDT). Financial & Physical Resources: Ensure efficient resource usage and assist with budget management, forecasting, and cost control. Provide support in developing business cases and monitor skill mix for the team. Manage the provision and safety of equipment in line with policies. Administration: Manage time effectively to balance patient care and non-clinical duties. Maintain accurate, confidential records, using paper or IT systems as specified in organizational policies. Participate in managing referrals and liaise with operational leads to support service delivery. People Using Our Services: Perform comprehensive geriatric assessments, collaborating with the MDT to support frail patients. Lead advanced care planning and ensure the proper documentation of care plans and treatment escalation. Provide clinical case management to prevent unnecessary hospital admissions and readmissions. Policy & Service Development: Lead or participate in audits and service improvement activities. Develop and implement policies and protocols to improve patient care and outcomes. Comply with national standards and guidelines, supporting the organization in maintaining high-quality care and compliance with Care Quality Commission (CQC) standards. Other Responsibilities: Develop competencies toward becoming an Independent Prescriber if appropriate for the profession. Participate in the annual appraisal process, ensuring ongoing learning and development. Work within professional and organizational standards, ensuring evidence-based practice. Communications & Relationships: Maintain strong relationships with multidisciplinary professionals and non-professionals. Ensure effective communication through appropriate forums, respecting patient confidentiality. Communicate sensitive information to patients, carers, and colleagues in a professional and compassionate manner. Physical & Mental Demands: Physical Demands: Moderate physical effort is required, including moving furniture in patient homes and transporting equipment. Daily driving and potentially working in adverse weather conditions. Mental Effort: Regularly performing complex assessments and prioritising tasks in response to urgent care needs. Handling interruptions and managing time-sensitive situations. Working Conditions: Exposure to bodily fluids, poor hygiene, and potential exposure to communicable diseases. Potential for encountering verbal and physical aggression, particularly in home visits. Additional Information: The post holder must adhere to all organizational policies and participate in mandatory training, including safeguarding and infection control. The role may involve engagement in research or audits, supporting sustainability and climate change initiatives. The job description is subject to review at least annually and may be updated in consultation with the postholder. Risk Management, Health & Safety, and Safeguarding: The role includes active participation in risk management, adhering to safety policies, and safeguarding children and adults. Regular updates on health and safety practices, infection control, and safeguarding policies are required. Sustainability & Climate Change: Employees are encouraged to reduce carbon emissions and contribute to sustainability efforts within the organisation. Other: The position requires adherence to the Working Time Regulations, with no staff expected to work over 48 hours per week unless in exceptional cases. Compliance with the organisation's no smoking and no alcohol policies is mandatory Job description Job responsibilities Job Title: Frailty Practitioner Band: Band 7 Locality: Adult Frailty and Specialist Services Base: Community Settings Responsible to: Integrated Operational Lead Job Purpose: The Frailty Practitioner leads on frailty care within community integrated teams. They use their expertise in physical and diagnostic assessments, medication reviews, and geriatric assessments (CGA) to help prevent hospital admissions and improve care for frail older adults. The role involves providing specialist advice, case management, and supporting multidisciplinary teams in comprehensive geriatric assessments. Departmental Position: The role reports to the Integrated Operational Lead for localities and works closely with various team leads in Adult Frailty and Specialist Services (AFSS). They play a key role in enhancing primary care and supporting service transformation for frailty services. Main Duties & Responsibilities: People Management: Plan and deliver frailty education programs for community team members, students, service users, and professionals. Manage staff tasks, including communication, appraisals, training, and performance management. Function as a clinical mentor and role model, supporting staff and students. Offer support in handling complaints and incidents, ensuring work is appropriately delegated to the multidisciplinary team (MDT). Financial & Physical Resources: Ensure efficient resource usage and assist with budget management, forecasting, and cost control. Provide support in developing business cases and monitor skill mix for the team. Manage the provision and safety of equipment in line with policies. Administration: Manage time effectively to balance patient care and non-clinical duties. Maintain accurate, confidential records, using paper or IT systems as specified in organizational policies. Participate in managing referrals and liaise with operational leads to support service delivery. People Using Our Services: Perform comprehensive geriatric assessments, collaborating with the MDT to support frail patients. Lead advanced care planning and ensure the proper documentation of care plans and treatment escalation. Provide clinical case management to prevent unnecessary hospital admissions and readmissions. Policy & Service Development: Lead or participate in audits and service improvement activities. Develop and implement policies and protocols to improve patient care and outcomes. Comply with national standards and guidelines, supporting the organization in maintaining high-quality care and compliance with Care Quality Commission (CQC) standards. Other Responsibilities: Develop competencies toward becoming an Independent Prescriber if appropriate for the profession. Participate in the annual appraisal process, ensuring ongoing learning and development. Work within professional and organizational standards, ensuring evidence-based practice. Communications & Relationships: Maintain strong relationships with multidisciplinary professionals and non-professionals. Ensure effective communication through appropriate forums, respecting patient confidentiality. Communicate sensitive information to patients, carers, and colleagues in a professional and compassionate manner. Physical & Mental Demands: Physical Demands: Moderate physical effort is required, including moving furniture in patient homes and transporting equipment. Daily driving and potentially working in adverse weather conditions. Mental Effort: Regularly performing complex assessments and prioritising tasks in response to urgent care needs. Handling interruptions and managing time-sensitive situations. Working Conditions: Exposure to bodily fluids, poor hygiene, and potential exposure to communicable diseases. Potential for encountering verbal and physical aggression, particularly in home visits. Additional Information: The post holder must adhere to all organizational policies and participate in mandatory training, including safeguarding and infection control. The role may involve engagement in research or audits, supporting sustainability and climate change initiatives. The job description is subject to review at least annually and may be updated in consultation with the postholder. Risk Management, Health & Safety, and Safeguarding: The role includes active participation in risk management, adhering to safety policies, and safeguarding children and adults. Regular updates on health and safety practices, infection control, and safeguarding policies are required. Sustainability & Climate Change: Employees are encouraged to reduce carbon emissions and contribute to sustainability efforts within the organisation. Other: The position requires adherence to the Working Time Regulations, with no staff expected to work over 48 hours per week unless in exceptional cases. Compliance with the organisation's no smoking and no alcohol policies is mandatory Person Specification Knowledge Essential Knowledge of Community Services/Third sector services suitable for frail patients Knowledge and understanding of legislation relevant to practice Experience of using electronic patient / service user record systems Understanding of frailty syndromes Skills Essential Ability to develop effective interpersonal relationships with colleagues in an MDT setting. Ability to communicate in a variety of settings with patients of varying levels of understanding. Ability to communicate unpleasant and sensitive information. Able to manage own workload, plan the work of others and work autonomously Logical and good at problem solving. Operational/organisational skills and ability to work and prioritise and work under pressure Demonstrable knowledge of assessment and therapeutic interventions in area of specialism Skills and experience of developing specialist programmes of care for an individual or groups of patients/clients and of providing highly specialist advice Skills for assessing and interpreting specialist patient/client conditions in order to make a clinical judgement regarding diagnosis and interventions. Skills to develop and deliver educational packages in frailty across the MDT Able to overcome barriers to understanding where there are physical or mental disabilities Ability to develop role to meet the changing needs of the service Ability to work across community locations in Plymouth,South Hams and West Devon Qualifications Essential Registered practitioner Professional knowledge acquired through degree supplemented by post graduate diploma with significant relevant experience. Specialist training and experience, short courses plus further specialist training Membership of the relevant Professional Body Evidence of recent professional development in an up-to-date portfolio Leadership and management qualification/training or evidence of experience in this area Independent prescriber Desirable Teaching qualification Additional clinical qualifications in Frailty/Older Persons Care Experience Essential Proven relevant post registration experience Experience of the management of patients living with frailty (predominantly older people) Experience of cross system and Multi Disciplinary Team working Experience in managing teams. Experience in designing training packages relevant to role Previous experience/delivery of formal/informal teaching of patients and staff Person Specification Knowledge Essential Knowledge of Community Services/Third sector services suitable for frail patients Knowledge and understanding of legislation relevant to practice Experience of using electronic patient / service user record systems Understanding of frailty syndromes Skills Essential Ability to develop effective interpersonal relationships with colleagues in an MDT setting. Ability to communicate in a variety of settings with patients of varying levels of understanding. Ability to communicate unpleasant and sensitive information. Able to manage own workload, plan the work of others and work autonomously Logical and good at problem solving. Operational/organisational skills and ability to work and prioritise and work under pressure Demonstrable knowledge of assessment and therapeutic interventions in area of specialism Skills and experience of developing specialist programmes of care for an individual or groups of patients/clients and of providing highly specialist advice Skills for assessing and interpreting specialist patient/client conditions in order to make a clinical judgement regarding diagnosis and interventions. Skills to develop and deliver educational packages in frailty across the MDT Able to overcome barriers to understanding where there are physical or mental disabilities Ability to develop role to meet the changing needs of the service Ability to work across community locations in Plymouth,South Hams and West Devon Qualifications Essential Registered practitioner Professional knowledge acquired through degree supplemented by post graduate diploma with significant relevant experience. Specialist training and experience, short courses plus further specialist training Membership of the relevant Professional Body Evidence of recent professional development in an up-to-date portfolio Leadership and management qualification/training or evidence of experience in this area Independent prescriber Desirable Teaching qualification Additional clinical qualifications in Frailty/Older Persons Care Experience Essential Proven relevant post registration experience Experience of the management of patients living with frailty (predominantly older people) Experience of cross system and Multi Disciplinary Team working Experience in managing teams. Experience in designing training packages relevant to role Previous experience/delivery of formal/informal teaching of patients and staff 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. Certificate of Sponsorship 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 (Opens in a new tab). From 6 April 2017, skilled worker applicants, applying for entry clearance into the UK, have had to present a criminal record certificate from each country they have resided continuously or cumulatively for 12 months or more in the past 10 years. Adult dependants (over 18 years old) are also subject to this requirement. Guidance can be found here Criminal records checks for overseas applicants (Opens in a new tab). UK Registration Applicants must have current UK professional registration. For further information please see NHS Careers website (opens in a new window). Additional information 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. Certificate of Sponsorship 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 (Opens in a new tab). From 6 April 2017, skilled worker applicants, applying for entry clearance into the UK, have had to present a criminal record certificate from each country they have resided continuously or cumulatively for 12 months or more in the past 10 years. Adult dependants (over 18 years old) are also subject to this requirement. Guidance can be found here Criminal records checks for overseas applicants (Opens in a new tab). 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 Livewell Southwest Address 200 Mount Gould Road Mount Gould Plymouth Devon PL4 7PY Employer's website https://www.livewellsouthwest.co.uk/ (Opens in a new tab)