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South Kerrier INT Frailty Lead The closing date is 10 August 2026
Working alongside the INT Clinical Lead, you will help shape & deliver high-quality, proactive, person-centred care for people living with frailty across the our neighbourhood.
This new senior clinical role offers the opportunity to lead the development of innovative frailty services, supporting early identification, comprehensive assessment & coordinated interventions that help people maintain independence, wellbeing & dignity at home.
You will champion evidence-based practice, provide expert clinical leadership & work collaboratively across primary care, community services, social care, voluntary organisations & secondary care. A key focus will be supporting practices & multidisciplinary teams across health, social & voluntary care to develop & embed a comprehensive frailty programme, ensuring people receive the right care, at the right time, in the right place.
The postholder will play a key role in service transformation, improving quality, developing integrated pathways & identifying more effective ways of working. You will also support monitoring, evaluation & reporting to measure the impact of new initiatives & drive continuous improvement.
This is an exciting opportunity for an experienced, forward-thinking clinician passionate about integrated care and improving outcomes for people living with frailty.
Part-time working (min 0.8 FTE) & Secondment opportunities will be considered for the right candidate. Secondment applicants must have line manager approval before applying
Main duties of the job Provide strategic direction and monitor progress to achieve South KerrierNeighbourhood objectives.
Whereappropriate advocate for change across South Kerrier to bring togethercommunity and practice teams.
Develop,implement and evaluate a seamless Proactive/Frailty support service across SouthKerrier, working with community and secondary care where appropriate, andaimed at continuously improving standards of patient care and widermulti-disciplinary team working.
Whereappropriate, support the development of discharge and contingency plans withrelevant professionals to arrange on-going care in residential, care home,hospital, community settings and at home;
Assistpatients to adapt to and manage their physical and mental health long-termconditions, through the teaching of coping strategies; and assess, plan, implement, and evaluate treatmentplans, with an aim to increase patients productivity and self-care;
Ensuredelivery of best practice in clinical practice, caseload management,education, research, and audit, to achieve South Kerrier local populationobjectives.
Advisepractices of workflow and develop SOPs for teams and practices to follow andimplement, particularly Personalised Care Planning, utilising best practice.
About us The SouthKerrier Integrated Neighbourhood Team (INT) supports a diverse and vibrantpopulation of more than 33,000 people across communities includingHelston, Carleen, Coverack, Constantine and the surrounding rural areas. We area collaborative, communityrooted team bringing together colleagues from health,social care, the voluntary sector, &independent providersto deliver joinedup, personcentred care.
Our sharedpurpose is simple: to help people live well, stay well, and receive the rightsupport at the right time. By working as one team across organisationalboundaries, we aim to reduce fragmentation, improve access to care, andstrengthen the resilience of our local communities.
A key focusfor our INT is enhancing the support available for people livingwith frailty. This includes proactive identification of those who maybenefit from early intervention, as well as responsive, coordinated care duringperiods of crisis or following events such as hospital admissions. We workclosely with primary care, community services, social care teams, and voluntarypartners to ensure that individuals and their families feel supported,informed, and empowered.
We are a teamthat values innovation, collaboration, and compassion.Whether we are redesigning pathways, supporting neighbourhood initiatives, orworking directly with individuals in their homes, we are committed to improvingoutcomes & delivering care that reflects the strengths & needs of the our community.
Job responsibilities Core Responsibilities
Provide strategic direction and monitor progress to achieve South Kerrier Neighbourhood objectives.
Where appropriate advocate for change across South Kerrier to bring together community and practice teams.
Develop, implement and evaluate a seamless Proactive/Frailty support service across South Kerrier, working with community and secondary care where appropriate, and aimed at continuously improving standards of patient care and wider multi-disciplinary team working.
Where appropriate, support the development of discharge and contingency plans with relevant professionals to arrange on-going care in residential, care home, hospital, community settings and at home;
Assist patients to adapt to and manage their physical and mental health long-term conditions, through the teaching of coping strategies; and assess, plan, implement, and evaluate treatment plans, with an aim to increase patients productivity and self-care;
Ensure delivery of best practice in clinical practice, caseload management, education, research, and audit, to achieve South Kerrier local population objectives.
Advise practices of workflow and develop SOPs for teams and practices to follow and implement, particularly Personalised Care Planning, utilising best practice.
- Provide professional leadership for the proactive care frailty service, offering guidance and support to the Proactive Nursing Team and neighbourhood clinical staff.
- Maintain clinical oversight of complex frailty patients, including providing direct clinical review where appropriate, to ensure safe and coordinated care across the neighbourhood team.
- Lead workforce planning, allocation of resources, and performance monitoring in collaboration with operational managers.
Ensure robust clinical governance structures are maintained, including incident review and risk management.
MDT
Ensure MDTs adhere to the Gold Standard Framework and lead MDT development and best practice across South Kerrier.
Ensure the right people are involved in MDTs from the South Kerrier Neighbourhood teams.
Participate in GP huddles and any other Partnership MDT and promote effective ways of working;
Exercise a critical understanding of personal scope of practice and to identify when a patient requires escalation or referring on to other services.
Develop effective working relationships with the Palliative Care Team and embed new processes and ways of working if required, to avoid duplication and to enhance the patient and family experience
Complex Case Management
Hold a case load of patients across South Kerrier.
Prescribe within your individual scope of practice and ensure that prescribing is undertaken in a safe, cost-effective manner.
Person Specification Education Training and Development
- Demonstrates self-development through continuous professional development activity;
- Demonstrates an understanding of current educational policies relevant to working areas of practice and keeps up to date with relevant clinical practice;
- Ensures appropriate clinical supervision is in place to support development;
- Identify opportunities for cross profession learning and skills acquisition ensuring appropriate education is developed, delivered and evaluated;
- Enrolled into review and appraisal systems within PCN.
Leadership
- Demonstrates understanding of the Proactive care service and is able to implement this appropriately within the workplace;
- Demonstrates understanding of, and contributes to, the implementation of South Kerrier Neighbourhood team vision;
- Demonstrates ability to improve quality within limitations of service;
- Reviews yearly progress and develops clear plans to achieve results within priorities set by others;
- Demonstrate ability to motivate self to achieve goals;
- Promotes diversity and equality in people management techniques and leads by example.
- Engages with Patient Participation Groups (PPGs) and involves PPGs in development of the role and practices
Experience
- Working at masters level or equivalent that encompasses the four pillars of clinical practice, leadership and management, education and research and adheres to the Multi professional framework for advanced clinical practice.
- Is able to plan, manage, monitor, advise and review general frailty care programmes for patients in core areas, including disease states/ long term conditions identified by local Needs Assessment;
- Demonstrates accountability for delivering professional expertise and direct service provision;
- Demonstrates problem-solving skills underpinned from perspectives and different models;
- Able to follow legal, ethical, professional and organisational policies/procedures and codes of conduct.
- Comprehensive digital skills to use different clinical systems; health applications for self-supportive care; risk stratification tools and general Microsoft office suite products.
Research and Evaluation
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