Frailty NurseNHS

Job summary

Totton Primary Care Network is seeking an experienced and motivated Frailty Nurse to join our multidisciplinary team, supporting the delivery of proactive, high-quality care to our frail and elderly population.

We have an exciting opportunity for an experience Frailty Nurse to join our established Primary Care Network (PCN). We serve the people of Totton and surrounding areas, including the outer parts of the New Forest, with a population of approximately 37,000 patients. We are an expanding and progressive organisation with excellent patient care as our central value. We are seeking to expand our care and support the delivery of pro-active, high quality care to our patients. This role is central to improving outcomes for patients living with frailty through early identification, personalised care planning, and coordinated working across primary, community, and secondary care services.

Main duties of the job

• 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.

Job description

Key Responsibilities

Clinical Responsibilities

• 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.

Multidisciplinary & Collaborative Working

• 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.

Service Development & Quality

• 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.

Professional Responsibilities

• 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.

About us

We have an exciting opportunity for an experience Frailty Nurse to join our established Primary Care Network (PCN). We serve the people of Totton and surrounding areas, including the outer parts of the New Forest, with a population of approximately 37,000 patients.