Job summary We are looking to expand our team with an enthusiastic Nurse, with a special interest in frailty, and passion for elderly care and multidisciplinary team working. You will be working flexibly across all four workstreams, but with a main focus on advanced care planning and providing proactive preventative care. Please note we also have a part time role available for this post. Main duties of the job Lead on the delivery of the Enhanced Health in Care Homes DES, including providing weekly care home rounds supporting proactive Person Centred Care Planning Person Centred Care Planning- By having a person-centred care approach it gives people more choice and control in their lives by providing an approach that is appropriate to the individual's needs. It involves a conversation shift from asking 'what's the matter with you' to 'what matters to you'. Early identification and recognition of deterioration to include proactive care and escalation planning Full Comprehensive Geriatric assessment for residents that have moderate to severe Frailty to support the coordination of care with community and urgent care services Understand the degree of frailty, mild moderate or severe and the 6 frailty syndromes enabling the correct proportionate response to a patient need To support proactive, anticipatory and advance care planning using an agreed set of validated, evidence based assessment tools to help identify the degree of need, e.g. Edmonton, SPICT/SPICT4ALL, Respect, RNT, CGA, EPaCCS Monitor and lead improvements to standards of care through, supervision of practice, clinical audit, evidence-based practice, teaching and supporting professional colleagues and the provision of skilled professional leadership. About us Lakeside Healthcare is a large GP partnership that provides NHS care for around 170,000 patients across Cambridgeshire, Peterborough, Northamptonshire and Lincolnshire. We are made of eight GP practices across 14 sites that are part of their local communities. We work together as practices to provide resilience, sharing learning and professional back-office support services. Our most important asset is our people, who provide care for our patients and help run our surgeries smoothly. We employ over 500 clinical and non-clinical staff, and we invest in training and developing to ensure that we retain and attract good quality staff who want to stay with us and be part of our team. We are proud of what we do and strive to demonstrate our values of Caring, Respect, Quality and Teamwork in everything we do. Date posted 09 April 2025 Pay scheme Other Salary £48,555 to £49,705 a year Contract Permanent Working pattern Full-time, Part-time Reference number A3007-25-0061 Job locations Lakeside Healthcare Ryhall Road Stamford Lincolnshire PE9 1YA Hereward Group Practice Exeter Street Bourne Lincolnshire PE10 9XR Job description Job responsibilities Four Counties Primary Care Network are establishing a collaborative multi-disciplinary service providing proactive Primary Care to our large Care Home population in Stamford, Bourne and villages. We are delivering four main workstreams on behalf of the 2 GP practices as part of the Enhanced Health in Care Home DES: 1. Enhanced primary care support 2. Multi-disciplinary team (MDT) support 3. Falls prevention, Reablement, and rehabilitation 4. High quality palliative and end-of-life care, Mental health, and dementia care We are looking to expand our team with an enthusiastic Nurse, with a special interest in frailty, and passion for elderly care and multidisciplinary team working. You will be working flexibly across all four workstreams, but with a main focus on advanced care planning and providing proactive preventative care. You will also be responsible for the following tasks: Lead on the delivery of the Enhanced Health in Care Homes DES, including providing weekly care home rounds supporting proactive Person Centred Care Planning Person Centred Care Planning- By having aperson-centred careapproach it gives people more choice and control in their lives by providing an approach that is appropriate to the individual's needs. It involves a conversation shift from asking 'what's the matter with you' to 'what matters to you' Early identification and recognition of deterioration to include proactive care and escalation planning Full Comprehensive Geriatric assessment for residents that have moderate to severe Frailty to support the coordination of care with community and urgent care services Understand the degree of frailty, mild moderate or severe and the 6 frailty syndromes enabling the correct proportionate response to a patient need To support proactive, anticipatory and advance care planning using an agreed set of validated, evidence based assessment tools to help identify the degree of need, e.g. Edmonton, SPICT/SPICT4ALL, Respect, RNT, CGA, EPaCCS Monitor and lead improvements to standards of care through, supervision of practice, clinical audit, evidence-based practice, teaching and supporting professional colleagues and the provision of skilled professional leadership. Identify and support educational opportunities to work with care homes, for example completion of Respect Documents, hydration and nutritional support and good oral health care. Working with other practitioners and agencies within the Primary Care Network and local system as necessary to develop patient specific treatment plans and ensure Care Pathways are utilised. Attendance through MDT working Provide continence support and management in conjunction with homes and community services Support necessary vaccination campaigns within care homes Provide high quality mental health and dementia care, offering support and guidance to homes, working in collaboration with community services Provide wound care support and advice in conjunction with homes and community services Undertake high standards of clinical record keeping including electronic data entry and recording of patient records Job description Job responsibilities Four Counties Primary Care Network are establishing a collaborative multi-disciplinary service providing proactive Primary Care to our large Care Home population in Stamford, Bourne and villages. We are delivering four main workstreams on behalf of the 2 GP practices as part of the Enhanced Health in Care Home DES: 1. Enhanced primary care support 2. Multi-disciplinary team (MDT) support 3. Falls prevention, Reablement, and rehabilitation 4. High quality palliative and end-of-life care, Mental health, and dementia care We are looking to expand our team with an enthusiastic Nurse, with a special interest in frailty, and passion for elderly care and multidisciplinary team working. You will be working flexibly across all four workstreams, but with a main focus on advanced care planning and providing proactive preventative care. You will also be responsible for the following tasks: Lead on the delivery of the Enhanced Health in Care Homes DES, including providing weekly care home rounds supporting proactive Person Centred Care Planning Person Centred Care Planning- By having aperson-centred careapproach it gives people more choice and control in their lives by providing an approach that is appropriate to the individual's needs. It involves a conversation shift from asking 'what's the matter with you' to 'what matters to you' Early identification and recognition of deterioration to include proactive care and escalation planning Full Comprehensive Geriatric assessment for residents that have moderate to severe Frailty to support the coordination of care with community and urgent care services Understand the degree of frailty, mild moderate or severe and the 6 frailty syndromes enabling the correct proportionate response to a patient need To support proactive, anticipatory and advance care planning using an agreed set of validated, evidence based assessment tools to help identify the degree of need, e.g. Edmonton, SPICT/SPICT4ALL, Respect, RNT, CGA, EPaCCS Monitor and lead improvements to standards of care through, supervision of practice, clinical audit, evidence-based practice, teaching and supporting professional colleagues and the provision of skilled professional leadership. Identify and support educational opportunities to work with care homes, for example completion of Respect Documents, hydration and nutritional support and good oral health care. Working with other practitioners and agencies within the Primary Care Network and local system as necessary to develop patient specific treatment plans and ensure Care Pathways are utilised. Attendance through MDT working Provide continence support and management in conjunction with homes and community services Support necessary vaccination campaigns within care homes Provide high quality mental health and dementia care, offering support and guidance to homes, working in collaboration with community services Provide wound care support and advice in conjunction with homes and community services Undertake high standards of clinical record keeping including electronic data entry and recording of patient records Person Specification Qualifications Essential Recognised professional degree, Registered with NMC Desirable Post registration course in palliative care, dementia, long term conditions or frailty Experience Essential Minimum 5 years post registration experience, Experience with Palliative and End of life Care, Experience with Dementia Care, Experience in Personalised Care Planning, Experience in Frailty identification and Comprehensive Geriatric Assessments, Experience working in a multidisciplinary team Person Specification Qualifications Essential Recognised professional degree, Registered with NMC Desirable Post registration course in palliative care, dementia, long term conditions or frailty Experience Essential Minimum 5 years post registration experience, Experience with Palliative and End of life Care, Experience with Dementia Care, Experience in Personalised Care Planning, Experience in Frailty identification and Comprehensive Geriatric Assessments, Experience working in a multidisciplinary team 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). 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. 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 Lakeside Healthcare Group Address Lakeside Healthcare Ryhall Road Stamford Lincolnshire PE9 1YA Employer's website https://www.lakesidehealthcaregroup.co.uk (Opens in a new tab)