PCN/INT Frailty Nurse

• Proactively identify patients with moderate to severe frailty using recognised frailty indices and practice registers
• Undertake comprehensive geriatric assessments (CGA), including functional, cognitive, social, and medication review
• Develop, document, and regularly review personalised care and support plans in partnership with patients, families and carers
• Identify patients at risk of unplanned hospital admission and initiate proactive interventions to reduce that risk
• Support patients and families with advance care planning discussions, including ReSPECT forms and end-of-life wishes, escalating to GPs or specialist palliative services as appropriate
• Recognise and respond appropriately to signs of clinical deterioration, escalating to GPs or emergency services where necessary

• Deliver structured weekly ward rounds at designated care homes
• Review resident health status, medication, and care plans in collaboration with care home staff
• Liaise with GPs to action clinical decisions arising from ward rounds
• Build strong working relationships with care home managers and staff to support early identification of resident health concerns

• Present complex and high-risk frailty patients at the monthly INT MDT meeting, providing clinical summaries and care plan updates
• Coordinate input and follow-up actions from MDT discussions across relevant services
• Work collaboratively with PCN Pharmacists, Social Prescribers, Care Coordinators and community teams to deliver joined-up, patient-centred care
• Act as a point of clinical liaison between general practice and community/social care services for frailty patients

• Maintain accurate, timely clinical records in line with practice and PCN information governance policies
• Contribute to PCN frailty data collection, audit, and outcome reporting
• Participate in relevant clinical audits and quality improvement initiatives
• Attend PCN and practice meetings as required

• Maintain NMC registration and up-to-date clinical competencies
• Participate in regular clinical supervision, appraisal, and revalidation processes
• Undertake training relevant to frailty, gerontology, and long-term condition management

Essential

• Significant post-registration nursing experience
• Experience working with frail, elderly or complex patients in community settings
• Experience presenting at or contributing to MDT meetings

Essential

• Highly organised to manage workload
• Collaborative team player
• Driver with access to a car to be able to travel between sites, predominantly across Nuneaton and Bedworth