Clinical Nurse Specialist

Livewell Southwest; Plymouth; On-site; GBP 40,000 - 50,000; Full time

Job summary

A community healthcare provider in Plymouth is seeking a Clinical Nurse Specialist to manage complex care for frail older adults. This role involves assessing, planning, and delivering evidence-based care while leading a multidisciplinary team. The ideal candidate should possess strong clinical skills, leadership abilities, and a passion for improving patient outcomes, focusing on reducing unnecessary hospital admissions. Join us to make a significant impact in community healthcare and support frail patients effectively.

Benefits

Protected CPD time

Training pathways and leadership programmes

Funding for qualifications

Qualifications

• Proven expertise in managing complex health and social care needs.
• Ability to lead a multidisciplinary team effectively.
• Experience in frailty assessments and management.

Responsibilities

• Deliver and coordinate specialist nursing care based on clinical standards.
• Manage a complex clinical caseload, ensuring integrated care delivery.
• Act as a Care Manager, promoting a person-centred approach.

Skills

Clinical triage skills

Enhanced clinical skills in assessment and patient management

Expertise in frailty, CGA, and clinical reasoning

Strong leadership and autonomy in a multidisciplinary team

Ability to deliver education and empower others in frailty care

Passion for improving patient outcomes and reducing hospital admissions

Operational Ward/People management skills

Job description

Are you passionate about improving the lives of frail older adults? Join our Community Frailty Virtual Ward as a Clinical Nurse Specialist!

In this rewarding role, you will complete frailty assessments and manage complex care for frail patients. Your expertise in physical assessments, diagnostic reasoning, and polypharmacy management will help prevent unnecessary hospital admissions supporting early supportive discharge from secondary care.

You will work with a multidisciplinary team (MDT) to provide high-quality care, supporting in the completion of Comprehensive Geriatric Assessments (CGA), and create treatment plans for patients facing crises with Frailty Syndromes or exacerbations of long‑term conditions to prevent unwanted hospital admissions. You will also deliver frailty education to patients, families, and professionals.

As a Clinical Nurse Specialist you will also have operational ward management for your 21 bed virtual ward and the staff under your line management.

What You will Bring:

• Clinical triage skills
• Enhanced clinical skills in assessment and patient management
• Expertise in frailty, CGA, and clinical reasoning
• Strong leadership and autonomy in a multidisciplinary team
• Ability to deliver education and empower others in frailty care
• Passion for improving patient outcomes and reducing hospital admissions
• Operational Ward/People management skills

Join us and make a lasting impact in community healthcare. We would love to hear from you!

Main duties of the job

You will:

Deliver & co‑ordinate specialist nursing care in line with national & local policy, professional standards & the NMC Code.

Manage a complex caseload within LWSW.

Act as Care Manager or Care Co‑ordinator, assessing, planning, implementing & evaluating evidence‑based care for patients with complex/long‑term conditions in partnership with carers & MDT.

Use enhanced clinical/assessment skills to promote independence, optimise health & quality of life & support behaviour change for patients with life‑limiting illness & frailty.

Provide expert clinical advice & support to colleagues.

Provide leadership & professional support to staff, identifying learning needs, promoting reflective & research‑based practice & fostering excellence in clinical care.

Contribute to service development, policy implementation & quality improvement initiatives through health needs assessment & change management.

Liaise effectively with primary, secondary & social care partners, maintain accurate clinical documentation & demonstrate sound judgement in managing risk & safeguarding.

Act as an autonomous practitioner & where qualified, a non‑medical prescriber.

Uphold patient safety, promote best practice, & model compassionate, person‑centred care within a dynamic & evolving Community Frailty Virtual Ward Service.

Please note that this role may not be eligible for sponsorship under the Skilled Worker route.

All LWSW staff are expected to be able & willing to work across a 7 day service.

About us

Livewell Southwest is an independent, award‑winning social‑enterprise delivering integrated health and social care services across Plymouth, South Hams, and West Devon, with specialist services in parts of Devon and Cornwall. Our teams work in community hospitals, GP practices, sports centres, and health hubs.

As an organisation with a strong social conscience we are guided by our values, kindness, respect, inclusivity, ambition, responsibility, and collaboration. We focus on transforming services to ensure sustainability, while empowering staff and those we serve.

We involve the people we care for, along with their families and carers, in shaping the care they receive, striving to deliver the right care at the right time and place. Centering our work on individual needs helps people lead healthy, independent lives.

We prioritise employees' development, offering protected CPD time, training pathways, leadership programmes, and funding for qualifications like the Care Certificate and Nurse Training Scholarships. Our induction and preceptorship programmes ensure a smooth transition into our organisation.

Livewell Southwest values diversity and encourages applications from all sections of the community, including those with armed forces experience, lived experience of mental health, neuro‑diverse conditions and learning disabilities. If you need assistance or reasonable adjustments during the application process, contact the Recruiting Manager listed in the job advert.

Job description

The post holder will deliver and co‑ordinate specialist nursing care within Livewell Southwest in line with the Nursing and Midwifery Council (NMC) Code, national guidance and local policy. The Specialist Nurse will manage a complex clinical caseload, providing expert assessment, diagnosis, care planning and review for individuals with complex health and social care needs. Acting as Care Manager or Care Co‑ordinator, the role promotes a positive, person‑centred approach to risk management, health promotion and self‑care, optimising independence and quality of life.

The post holder will use advanced clinical skills and specialist knowledge to lead the planning and delivery of high‑quality, evidence‑based care. They will act as a clinical expert, providing professional advice, supervision and education to colleagues, supporting excellence and consistency across the service.

Scope and Range

The Specialist Nurse will work autonomously within the boundaries of professional practice, providing care across community settings, including patient homes, clinics, and care facilities. The role may include non‑medical prescribing (V300) in accordance with the local formulary and professional guidelines. The post holder will contribute to service development, clinical leadership, and strategic planning, deputising for the Operational Manager as required and ensuring continuity of service during periods of change or increased demand.

Key Responsibilities

Clinical Practice

• Manage and co‑ordinate a defined, complex nursing caseload using evidence‑based assessment, diagnosis, and care planning in partnership with patients, carers, and multidisciplinary teams.

• Deliver person‑centred care that promotes independence, prevents unnecessary hospital admissions, and supports early discharge where appropriate.

• Provide holistic and specialist clinical interventions, including advanced physical assessments, history taking, and formulation of treatment and management plans.

• Undertake non‑medical prescribing within scope of competence and in accordance with local and national policy.

• Facilitate case conferences, complex discharge planning, and multidisciplinary reviews to ensure integrated care delivery.

• Promote and implement strategies for health promotion, disease prevention and behaviour change for individuals with long‑term or life‑limiting conditions.

• Conduct risk assessments and implement safeguarding procedures to protect vulnerable adults and children in line with organisational policy.

• Maintain accurate, contemporaneous clinical records using electronic and paper systems, ensuring compliance with professional and organisational standards.

• Participate in clinical audit, quality assurance, and research activities to maintain high standards of care.

Leadership and Management

• Provide clinical leadership to nurses and health care professionals within the team, modelling excellence in practice and professional behaviour.

• Support the Operational Manager by undertaking delegated management duties, including supervision, appraisal, recruitment, and workforce planning.

• Identify training needs and contribute to the professional development of staff through supervision, mentorship, and teaching.

• Promote reflective practice, critical thinking and evidence‑based decision‑making across the team.

• Deputise for the Operational Manager during periods of absence, ensuring effective day‑to‑day service operation.

• Participate in rota management, leave planning and workload allocation to maintain safe staffing levels.

• Lead on investigating and responding to complaints, incidents, and Patient Safety Incident Response Framework processes, ensuring lessons are learned and shared.

• Support a culture of continuous improvement, encouraging innovation, service redesign and clinical excellence.

Partnership and Communication

• Build and maintain strong relationships with primary care, secondary care, mental health, and social care colleagues to support integrated service delivery.

• Act as a professional and clinical resource for patients, families, carers, and colleagues, providing education, guidance and emotional support.

• Communicate complex and sensitive information effectively, managing barriers such as distress, cognitive impairment, or language differences.

• Represent the service at internal and external meetings, promoting the work of Livewell Southwest and contributing to collaborative service developments.

• Ensure patient confidentiality and compliance with data protection and consent legislation at all times.

Quality, Governance and Professional Standards

• Uphold the NMC Code and demonstrate professional accountability at all times.

• Participate in the development, implementation and monitoring of local policies, guidelines, and pathways to ensure safe, effective practice.

• Use clinical audit, research and feedback to inform continuous service improvement.

• Maintain own clinical competence through ongoing professional development, reflective practice, and mandatory training.

• Contribute to service evaluation, caseload profiling, and population health assessments to identify and address unmet needs.

• Support the implementation of evidence‑based initiatives, contributing to the transformation of community services in line with NHS priorities.

• Adhere to infection prevention and control, health and safety, and risk management policies, reporting incidents and near‑misses promptly.

• Participate in supervision and annual appraisal, developing and reviewing a personal development plan in line with professional revalidation requirements.

Education and Training

• Act as mentor, assessor, and clinical educator for student nurses, pre‑registration learners, and new staff.

• Support continuous learning within the team through in‑service training, clinical supervision and reflective sessions.

• Contribute to the development of local education programmes and competency frameworks relevant to the specialist area.

• Participate in teaching and promoting best practice in clinical areas including frailty, long‑term condition management, palliative care and health promotion.

Financial and Resource Management

• Ensure the effective use of equipment and resources in a cost‑efficient manner.

• Maintain authorisation for ordering and stock control within budgetary limits.

• Support resource governance through safe and effective prescribing and procurement practices.

• Demonstrate awareness of statutory and non‑statutory funding processes when commissioning or advocating for services on behalf of patients.

Service Development

• Lead and participate in projects aimed at improving service quality, access, and patient outcomes.

• Use health needs assessment and risk‑stratification tools to identify and address gaps in care provision.

• Contribute to policy review, development and implementation at local and organisational level.

• Engage with professional forums and steering groups to shape strategic direction and influence best practice.

• Promote sustainable, patient‑focused care models that support the NHS Long Term Plan and local priorities.

Research and Audit

• Participate in clinical