Proactive Care / Care Homes ANP

• Deliver advanced, holistic clinical care to patients in care home settings.
• Identify and respond to early signs of deterioration, including escalation planning.
• Assess and manage acute, chronic, and complex conditions related to frailty.
• Prescribe and deprescribe safely within scope of practice and professional competencies.
• Undertake Comprehensive Geriatric Assessments to inform care planning and coordination.
• Order, perform, and interpret diagnostic tests and investigations.
• Initiate diagnosis for long-term conditions (e.g. diabetes, COPD, asthma, IHD) and refer appropriately.
• Directly admit patients to secondary care when clinically indicated.

• Deliver proactive, anticipatory, and advance care planning using evidence-based tools (e.g. ReSPECT, EPaCCS).
• Undertake holistic, person-centred needs assessments and develop individual care plans.
• Maintain and manage a caseload of care homes patients.
• Collaborate with the multidisciplinary team (MDT) to develop and implement patient-specific care pathways.
• Proactively manage long-term conditions and support admission avoidance strategies.

• Work independently and in partnership with GPs and the wider MDT.
• Communicate effectively with healthcare professionals to ensure coordinated care.
• Build and maintain strong relationships with statutory, voluntary, and third-sector organisations.
• Organise, chair, and contribute to MDT meetings to support integrated care delivery.
• Advocate for patients and families where necessary.

• Promote health, wellbeing, and independence for patients in care home settings.
• Provide education to patients and carers to support self-management and behaviour change.
• Support vaccination programmes within care homes.
• Deliver education and guidance to care home staff (e.g. nutrition, hydration, oral care, ReSPECT planning).

• Work flexibly across GP practices, and care homes
• Support Proactive Care Coordinators in delivering high-quality care.
• Contribute to service development and innovation in Proactive Care pathways.
• Participate in audits, data collection, and quality improvement initiatives.
• Contribute to achieving local and national targets and maintaining disease registers.

• Maintain accurate, contemporaneous patient records using EMIS and SystmOne.
• Ensure compliance with CQC standards and relevant policies (e.g. infection control, safeguarding, risk management).
• Promote safe medication management practices.
• Support effective communication within the PCN and across partner organisations.
• Contribute to contractual and reporting requirements.

• Maintain high standards of professional practice, conduct, and clinical excellence.
• Participate in appraisal processes and align objectives with organisational goals.
• Undertake mandatory training and continuing professional development.
• Keep up to date with current guidelines, policies, and contractual changes.
• Engage in reflective practice and lifelong learning.

• Attend and actively contribute to team, practice, and PCN meetings.
• Work within all relevant policies, procedures, and professional standards.
• Maintain confidentiality and uphold information governance requirements.
• Carry out any other duties commensurate with the role.

Essential

• Understanding of Personalised Care
• Understanding of the wider determinants of health
• Knowledge of how the NHS works, including primary care and PCNs
• Ability to recognise/work within limits of competence, seeking advice if needed
• Understanding of the needs of older people / adults with disabilities / long term conditions particularly in relation to promoting their independence
• Basic knowledge of long-term conditions and associated complexities: medical, physical, emotional and social
• Clear, polite telephone manner
• Good interpersonal skills
• Ability to record accurate clinical notes
• EMIS and SystmOne user skills
• Proficient in MS Office and web-based services

Essential

• Teamwork: Work effectively and professionally within the frailty team through willingness to proactively support and assist peers and colleagues
• Autonomous: Ability to work independently by making informed decisions based on professional knowledge and clinical judgement
• Solution Focussed: Ability to react to and face challenges or setbacks in a positive manner with a commitment to continuous improvement
• Ability to actively listen, empathise with people and provide personalised support in a non-judgemental way.
• Ability to provide a culturally sensitive service supporting people from all backgrounds and communities, respecting lifestyles and diversity
• Commitment to reducing health inequalities and proactively working to reach people from diverse communities
• Ability to support people in a way that inspires trust and confidence, motivating others to reach their potential
• Ability to communicate effectively, both verbally and in writing, with people, their families, carers, partner agencies and stakeholders
• Ability to provide motivational coaching to support peoples behaviour change
• Ability to identify risk and assess / manage risk when working with individuals
• Strong awareness and understanding of when necessary to refer people to other health professionals, when the need is beyond the scope of Frailty Nurse role
• Ability to maintain effective working relationships and promote collaboration
• Personal accountability, emotional resilience, ability to work well under pressure
• Ability to organise, plan and prioritise on own initiative, including when under pressure and meeting deadlines
• Ability to work flexibly and enthusiastically within a team or on own initiative
• Knowledge of and ability to work to policies & procedures, e.g. confidentiality, safeguarding, lone working, information governance, and health and safety
• Demonstrable commitment to professional and personal development

Essential

• Meets an enhanced Disclosure and Barring Service (DBS) check
• Access to own transport and ability to travel across the PCN on a regular basis

Essential

• Current UK NMC registration and maintains revalidation
• Relevant nursing or health degree
• Up to date vaccinations and immunisations training for Covid/Influenza
• Evidence of continual professional development
• Full UK Driving Licence

Essential

• Five years recent primary or community nursing experience
• Experience of Palliative and End of life Care
• Experience of working within multi - professional team environments
• Experience with Dementia Care
• Experience in Personalised Care Planning
• Experience in Frailty identification and Comprehensive Geriatric Assessments
• Experience of supporting people, their families and carers in a related role
• Experience or training in personalised care and support planning

Desirable

• - Experience of data collection and using tools to measure the impact of services