To support the provision of clinical care for identified patients with frail and/or complex needs usually in their own homes in accordance with the patients care plan To establish and maintain effective communications with patients, carers, and health professionals in a professional manner To assist with ongoing support of patients, their families, and carers to manage their frailty and long-term health conditions To be able to identify and recognise a deterioration in an individuals health and act promptly to refer to relevant health professional to minimise the risk of rapid deterioration or where appropriate, avoid hospital admission In line with the PCN/ Practices Team policy, to update patient records ensuring entries are accurate, relevant, and timely and communicate care provided appropriately Following appropriate competency-based training, to undertake delegated clinical tasks and procedures such as, phlebotomy, ECG, BMI/BP readings and urinalysis To develop and maintain effective working relationships with health and social care colleagues and other agencies to ensure that frail and complex patients receive a consistent, integrated response to all contacts/referrals To demonstrate an ability to undertake duties in an autonomous manner To understand and follow procedures and policies on information governance, with strict adherence to protocols regarding the sharing of personal and confidential information between different organisations and individuals To contribute to the ongoing development of the service and participate in team meeting

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