Advanced Care Practitioner - Frailty

The ACP will play a key role in delivering the Frailty programme

across the Primary Care Network. Working as part of a multidisciplinary team,

the post holder will provide proactive, holistic care for patients living with

frailty and complex health needs, with a particular focus on housebound

patients, care home residents, patients receiving palliative care and those

identified through the PCN's frailty registers.

The post holder will undertake comprehensive geriatric

assessments (CGAs), coordinate care, support anticipatory care planning and

work collaboratively with patients, carers and partner organisations to improve

patient outcomes, promote independence and reduce avoidable emergency

department attendances and hospital admissions.

Deliver high-quality, patient-centred nursing

care for patients living with frailty across GP practices, patients' own homes

and care home settings.

Undertake comprehensive geriatric assessments

(CGAs), assessing patients' physical, psychological, functional and social

needs, and contribute to personalised care planning.

Develop and review anticipatory care plans in

partnership with patients, carers and the multidisciplinary team.

Monitor patients with frailty and complex needs,

identifying changes in health status and escalating concerns appropriately.

Recognise and manage common frailty syndromes

including falls, delirium, immobility, continence issues, malnutrition and

medication-related problems.

Assess nutritional risk where appropriate and

work collaboratively with dietitians, pharmacists and other healthcare

professionals to optimise nutritional care.

Work alongside the PCN pharmacy team and other

prescribers to support structured medication reviews and medicines

optimisation.

Carry out cognitive assessments where

appropriate and make timely referrals to memory assessment services and other

specialist services in accordance with local pathways.

Identify patients who may benefit from a

palliative approach to care and facilitate referrals to appropriate services.

Support patients and clinicians with ReSPECT

discussions and documentation, ensuring patients' wishes are appropriately

recorded.

Record patients' preferred place of care and

preferred place of death where appropriate.

Multidisciplinary Working

Work collaboratively within multidisciplinary

team (MDT) meetings, contributing to case discussions and coordinated care

planning.

Develop effective working relationships with

GPs, pharmacists, community nurses, therapists, geriatricians, social care,

care home staff, hospices and voluntary sector organisations.

Quality, Governance and Service Development

Support practices with frailty identification,

dementia and palliative care coding, ensuring accurate clinical records.

Maintain accurate, contemporaneous documentation

using EMIS Web and ensure appropriate clinical coding.

Contribute to clinical audit, service

evaluation, quality improvement initiatives and data collection to support

delivery of the Single Neighbourhood programme.

Participate in reporting requirements and

service evaluation, including preparation of information for the ICB where

required.

Ensure compliance with CQC standards,

safeguarding policies, NICE guidance and local clinical policies.

Participate in mandatory training, clinical

supervision, appraisal and continuing professional development.

Practise in accordance with the NMC Code and

maintain professional registration at all times

General Responsibilities

Maintain patient confidentiality and comply with

GDPR and Information Governance requirements.

Work flexibly across the PCN to meet service

needs.

Undertake any other duties commensurate with the

grade of the post

You will be employed by Widnes Highfield Health - GP

Federation on behalf of Widnes Primary Care Network our head office is located

on the site of a former maternity hospital in Widnes, Cheshire. The building has since been renovated to

create comfortable waiting areas and clinic rooms filled with state-of-the-art

facilities and equipment. The setting

gives us access to the latest technology, enabling accurate and timely assessment

and sharing of results for our patients, forming a core part of the healthcare

on offer in Halton.

The GP Federation is a provider of services- Widnes

Highfield Health and Wellbeing Centre, Primary Care, Halton

The patient list size of Widnes PCN is 68,000 over 8

practices.

Bevan Group Practice, Fir Park Medical Centre, Hough Green Health Park, Newtown Surgery, Oaks Place Surgery, Peel House Medical Plaza, The Beeches Medical Centre and Upton Rocks Surgery

In the past 12 months Widnes

Highfield Health and WA8 Collaborate (PCN) have successfully won and been

shortlisted for several national awards, highlighting our collaborative work.

2025 HSJ award winner for Most Effective Contribution to

Improving Care for Patients with Long Term Conditions

2025 HSJ runner up for our collaborative work in

cardio-renal-metabolic transformation

2025 GP Awards winner for Clinical Improvement Long Term

Conditions - A Cardio-Renal-Metabolic Quality Improvement Programme.

2025 GP Awards shortlisted for PCN of the Year.

Experience

Other

Knowledge and Skills

Personal Attributes

Qualifications