Frailty Nurse

• Undertake comprehensive frailty assessments, including clinical, functional, psychological, and social aspects of care.
• Develop, implement, and regularly review personalised care and support plans in collaboration with patients, carers, and the wider MDT.
• Provide clinical reviews and ongoing monitoring for patients identified as moderately or severely frail.
• Support admission avoidance through early intervention, escalation planning, and coordination with community and acute services.
• Contribute to anticipatory care planning, including end-of-life and advance care planning where appropriate.

• Participate in MDT meetings, case discussions, and proactive care planning forums.
• Act as a clinical resource for frailty-related advice within the PCN.
• Liaise with secondary care, community services, and voluntary sector organisations to ensure seamless care pathways.

• Support quality improvement initiatives related to frailty and proactive care.
• Ensure accurate and timely clinical documentation in patient records.
• Maintain awareness of current best practice, guidelines, and evidence relating to frailty care.

• Undertake comprehensive frailty assessments, including clinical, functional, psychological, and social aspects of care.
• Develop, implement, and regularly review personalised care and support plans in collaboration with patients, carers, and the wider MDT.
• Provide clinical reviews and ongoing monitoring for patients identified as moderately or severely frail.
• Support admission avoidance through early intervention, escalation planning, and coordination with community and acute services.
• Contribute to anticipatory care planning, including end-of-life and advance care planning where appropriate.

• Work closely with GPs, ANPs, Care Coordinators, Social Prescribers, pharmacists, and community teams.
• Participate in MDT meetings, case discussions, and proactive care planning forums.
• Act as a clinical resource for frailty-related advice within the PCN.
• Liaise with secondary care, community services, and voluntary sector organisations to ensure seamless care pathways.

• Contribute to the development and delivery of PCN frailty services in line with DES requirements.
• Support quality improvement initiatives related to frailty and proactive care.
• Ensure accurate and timely clinical documentation in patient records.
• Maintain awareness of current best practice, guidelines, and evidence relating to frailty care.

• Maintain NMC registration and adhere to the NMC Code of Professional Conduct.
• Take responsibility for own professional development and mandatory training.
• Participate in clinical supervision, appraisal, and revalidation processes.
• Work within PCN policies, procedures, and governance frameworks.

Essential

• Registered Nurse with current NMC registration
• Experience working with older adults and/or patients living with
• frailty
• Experience of clinical assessment and care planning
• Experience working within primary care, community services, or
• a similar healthcare setting
• Strong clinical assessment and decision-making skills
• Knowledge of frailty, long-term conditions, and proactive care
• approaches
• Ability to work autonomously and manage a clinical caseload
• Excellent communication and interpersonal skills
• Ability to work collaboratively within a multidisciplinary team
• Good IT skills and ability to maintain accurate clinical records
• Organised, flexible, and adaptable approach to work
• Patient-centred and compassionate care approach
• Ability to manage workload effectively and prioritise competing
• demands
• Commitment to equality, diversity, and inclusion
• Willingness to travel between PCN sites as required
• Commitment to ongoing professional development

Desirable

• Experience of proactive or anticipatory care
• Experience working with care homes or long-term conditions
• Experience of working within a PCN or MDT setting
• Degree-level qualification or equivalent experience
• Non-medical prescribing qualification or willingness to work
• towards
• Knowledge of PCN structures and DES requirements
• Understanding of population health and personalised care

Essential

• Registered Nurse with current NMC registration
• Experience working with older adults and/or patients living with
• frailty
• Experience of clinical assessment and care planning
• Experience working within primary care, community services, or
• a similar healthcare setting
• Strong clinical assessment and decision-making skills
• Knowledge of frailty, long-term conditions, and proactive care
• approaches
• Ability to work autonomously and manage a clinical caseload
• Excellent communication and interpersonal skills
• Ability to work collaboratively within a multidisciplinary team
• Good IT skills and ability to maintain accurate clinical records
• Organised, flexible, and adaptable approach to work
• Patient-centred and compassionate care approach
• Ability to manage workload effectively and prioritise competing
• demands
• Commitment to equality, diversity, and inclusion
• Willingness to travel between PCN sites as required
• Commitment to ongoing professional development

Desirable

• Experience of proactive or anticipatory care
• Experience working with care homes or long-term conditions
• Experience of working within a PCN or MDT setting
• Degree-level qualification or equivalent experience
• Non-medical prescribing qualification or willingness to work
• towards
• Knowledge of PCN structures and DES requirements
• Understanding of population health and personalised care