Welwyn Garden City PCN Frailty NurseNHS

Job summary

An exciting opportunity has arisen for an experienced Registered Nurse to join Welwyn Garden City PCN as a Frailty Nurse. Working 3 days a week across two of our member surgeries, you will lead on the proactive identification, review, and management of frail patients, deliver weekly ward rounds at two local care homes, and represent frailty patients at the monthly Integrated Neighbourhood Team (INT) Multidisciplinary Team (MDT).

This role is central to our PCN's frailty strategy, working closely with GPs, care home staff, the wider INT, and community services to deliver proactive, person-centred care that helps frail and elderly patients stay well and supported in their usual place of residence.

Main duties of the job

• Undertake proactive comprehensive geriatric assessments and structured medication reviews for patients identified as moderately to severely frail
• Develop and maintain personalised care and support plans with patients, carers, and families
• Deliver weekly ward rounds at two local care homes, providing clinical review, care planning, and liaison with care home staff
• Identify and manage patients at risk of unplanned hospital admission, working proactively to anticipate and prevent crises
• Present complex and high-risk patients on a monthly basis at the INT MDT, coordinating input from wider health and social care partners
• Work closely with GPs, PCN pharmacists, social prescribers, and community teams to ensure coordinated, joined-up care
• Support advance care planning conversations, including ReSPECT and end-of-life discussions where appropriate
• Maintain accurate clinical records and contribute to PCN frailty data and outcome reporting

Job description

Job PurposeThe PCN Frailty Nurse will work as part of the Primary Care Network's multidisciplinary team to proactively identify, assess, and manage patients living with frailty. The post-holder will provide structured clinical review for frail patients across two PCN member practices, deliver weekly ward rounds at two local care homes, and represent the frailty caseload at the monthly Integrated Neighbourhood Team (INT) Multidisciplinary Team (MDT) meeting.

The role is designed to reduce avoidable hospital admissions, improve continuity of care for frail and elderly patients, and strengthen coordination between general practice, care homes, and wider community and social care services.

Key Working Relationships

• GPs and clinical staff across PCN member practices
• Care home managers and nursing/care staff
• Integrated Neighbourhood Team (INT) members, including community nursing, palliative care teams, social care, and mental health services
• PCN Clinical Pharmacists and Social Prescribing Link Workers
• Patients, families, and informal carers
• Secondary care and discharge teams, as needed

Main Duties and ResponsibilitiesClinical Care

• 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

Care Home Ward Rounds

• Deliver structured weekly ward rounds at two designated local 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

Multidisciplinary Working

• 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, 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

Administration and Governance

• 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

Professional Development

• 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
• Keep up to date with national and local guidance relevant to frailty care (e.g. NICE, BGS, local ICB pathways)

Confidentiality and Information GovernanceThe post-holder must maintain strict confidentiality regarding patient, staff, and organisational information in line with the Data Protection Act 2018, UK GDPR, and Caldicott principles.

Health and SafetyThe post-holder is required to comply with the PCN and host practices' health and safety policies, including infection control, safe manual handling, and lone-working procedures where relevant to care home and community visits.

Equality and DiversityThe post-holder must act in accordance with the PCN's equality, diversity, and inclusion policies, treating patients, carers, and colleagues with dignity and respect at all times.

Variation to This Job Description

This job description reflects the current requirements of the role. As the PCN's frailty service develops, the responsibilities may be reviewed and amended in consultation with the post-holder.

About us

Welwyn Garden City PCN brings together a group of three local GP practices working collaboratively to deliver proactive, coordinated care to our patient population. We are expanding our multidisciplinary team and offer a supportive environment with strong links across general practice, community services, and social care.