Advanced Care Practitioner - Frailty

Cardiff and Vale University Health Board; Runcorn; On-site; GBP 55,000 - 64,000; Full time

Job summary

Widnes Highfield Health - GP Federation on behalf of Widnes Primary Care Network seeks an Advanced Clinical Practitioner to deliver proactive, holistic care for frail and complex patients. You will conduct CGAs, coordinate multidisciplinary care across GP practices, homes and care homes, and support anticipatory planning.

The role focuses on housebound patients, palliative care, and reducing emergency attendances.

Qualifications

• Experience working with older people and/or patients living with frailty.
• Experience undertaking holistic patient assessments.
• Experience managing patients with multiple long-term conditions.
• Experience of multidisciplinary working.
• Experience of care planning and care coordination, within Primary Care.
• Full UK driving licence and access to a vehicle (or ability to travel across PCN).
• Knowledge of frailty and CGA, ReSPECT and advance care planning.

Responsibilities

• Undertake comprehensive geriatric assessments (CGAs) and coordinate care.
• Deliver proactive, person-centred care for adults living with frailty.
• Promote anticipatory care planning and reduce avoidable admissions.
• Work across GP practices, patients' homes and care homes within MDT.

Skills

Excellent communication

Interpersonal skills

Independent working

Multidisciplinary working

Prioritise workload

Organisational skills

Patient-centred

Compassionate

Education

Degree level education

Masters diploma in Advanced Clinical Practice/Health Assessment

MSc Advanced Practice

NMC or HCPC registered

Independent Prescriber

Tools

EMIS Web

Job description

Widnes Primary Care Network is launching an innovative new frailty service and are looking for a passionate, skilled, and motivated Advanced Clinical Practitioner to join our growing team. Working across our member practices, patients' own homes and care home settings, you will play a key role in providing proactive, person-centred care for adults living with frailty and complex health needs. As part of a supportive multidisciplinary team, you will undertake comprehensive geriatric assessments, coordinate care, promote anticipatory care planning and work collaboratively to improve patient outcomes and help reduce avoidable hospital admissions. This is an excellent opportunity for an enthusiastic and compassionate practitioner who enjoys autonomous working, values integrated care and is passionate about improving the lives of frail/older people.

The ACP will play a key role in delivering the Frailty programme across the Primary Care Network. Working as part of a multidisciplinary team, the post holder will provide proactive, holistic care for patients living with frailty and complex health needs, with a particular focus on housebound patients, care home residents, patients receiving palliative care and those identified through the PCN's frailty registers. The post holder will undertake comprehensive geriatric assessments (CGAs), coordinate care, support anticipatory care planning and work collaboratively with patients, carers and partner organisations to improve patient outcomes, promote independence and reduce avoidable emergency department attendances and hospital admissions.

Deliver high-quality, patient-centred nursing care for patients living with frailty across GP practices, patients' own homes and care home settings. Undertake comprehensive geriatric assessments (CGAs), assessing patients' physical, psychological, functional and social needs, and contribute to personalised care planning. Develop and review anticipatory care plans in partnership with patients, carers and the multidisciplinary team. Monitor patients with frailty and complex needs, identifying changes in health status and escalating concerns appropriately. Recognise and manage common frailty syndromes including falls, delirium, immobility, continence issues, malnutrition and medication-related problems. Assess nutritional risk where appropriate and work collaboratively with dietitians, pharmacists and other healthcare professionals to optimise nutritional care. Work alongside the PCN pharmacy team and other prescribers to support structured medication reviews and medicines optimisation. Carry out cognitive assessments where appropriate and make timely referrals to memory assessment services and other specialist services in accordance with local pathways. Identify patients who may benefit from a palliative approach to care and facilitate referrals to appropriate services. Support patients and clinicians with ReSPECT discussions and documentation, ensuring patients' wishes are appropriately recorded. Record patients' preferred place of care and preferred place of death where appropriate.

Multidisciplinary Working Work collaboratively within multidisciplinary team (MDT) meetings, contributing to case discussions and coordinated care planning. Develop effective working relationships with GPs, pharmacists, community nurses, therapists, geriatricians, social care, care home staff, hospices and voluntary sector organisations. Quality, Governance and Service Development Support practices with frailty identification, dementia and palliative care coding, ensuring accurate clinical records. Maintain accurate, contemporaneous documentation using EMIS Web and ensure appropriate clinical coding. Contribute to clinical audit, service evaluation, quality improvement initiatives and data collection to support delivery of the Single Neighbourhood programme. Participate in reporting requirements and service evaluation, including preparation of information for the ICB where required. Ensure compliance with CQC standards, safeguarding policies, NICE guidance and local clinical policies. Participate in mandatory training, clinical supervision, appraisal and continuing professional development. Practise in accordance with the NMC Code and maintain professional registration at all times General Responsibilities Maintain patient confidentiality and comply with GDPR and Information Governance requirements. Work flexibly across the PCN to meet service needs. Undertake any other duties commensurate with the grade of the post.

• Experience working with older people and/or patients living with frailty
• Experience undertaking holistic patient assessments
• Experience managing patients with multiple long-term conditions
• Experience of multidisciplinary working
• Experience of care planning and care coordination, Experience within Primary Care
• Community or District Nursing experience
• Care home nursing experience
• Experience of the Enhanced Health in Care Homes (EHCH) model
• Experience of quality improvement or service development, Full UK driving licence and access to a vehicle (or ability to travel independently across the PCN)
• Willingness to work across multiple sites including GP practices, patients' homes and care homes, Understanding of frailty and Comprehensive Geriatric Assessment (CGA
• Knowledge of long-term condition management
• Knowledge of safeguarding adults
• Understanding of dementia, delirium and end of life care
• Understanding of ReSPECT and advance care planning
• Excellent communication and interpersonal skills
• Ability to undertake holistic clinical assessments
• Ability to prioritise workload and manage a caseload independently
• Strong organisational and time management skills
• Ability to work collaboratively across organisational boundaries
• Competent IT skills, including electronic patient record systems (e.g. EMIS Web)
• Accurate clinical documentation and coding, Compassionate, caring and patient-centred
• Flexible and adaptable
• Able to work independently and as part of a multidisciplinary team
• Committed to continuous professional development and service improvement
• Professional, approachable and resilient, Degree Level education, NMC or HCPC registered
• Masters diploma in Advanced Clinical Practice/Health Assessment or equivalent post-graduate study Level 7
• MSc Advanced Practice/ willingness to complete MSc Advanced Practice
• Independent Prescriber (or PGD qualification for Professions without prescribing within professional competencies)

You will be employed by Widnes Highfield Health - GP Federation on behalf of Widnes Primary Care Network our head office is located on the site of a former maternity hospital in Widnes, Cheshire. The building has since been renovated to create comfortable waiting areas and clinic rooms filled with state-of-the-art facilities and equipment. The setting gives us access to the latest technology, enabling accurate and timely assessment and sharing of results for our patients, forming a core part of the healthcare on offer in Halton.

The GP Federation is a provider of services- Widnes Highfield Health and Wellbeing Centre, Primary Care, Halton The patient list size of Widnes PCN is 68,000 over 8 practices. Bevan Group Practice, Fir Park Medical Centre, Hough Green Health Park, Newtown Surgery, Oaks Place Surgery, Peel House Medical Plaza, The Beeches Medical Centre and Upton Rocks Surgery In the past 12 months Widnes Highfield Health and WA8 Collaborate (PCN) have successfully won and been shortlisted for several national awards, highlighting our collaborative work. 2025 HSJ award winner for Most Effective Contribution to Improving Care for Patients with Long Term Conditions 2025 HSJ runner up for our collaborative work in cardio-renal-metabolic transformation 2025 GP Awards winner for Clinical Improvement Long Term Conditions - A Cardio-Renal-Metabolic Quality Improvement Programme.

This is a 12-month fixed term contract with the potential to becoming a permanent post, salary range is £55,000 - £64,000 depending on experience and NHS pension.