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A community healthcare provider is seeking a Clinical Nurse Specialist to enhance the lives of frail older adults in Plymouth. This role involves managing complex care, conducting frailty assessments, and leading a multidisciplinary team. The ideal candidate will have strong clinical skills, a passion for patient care, and leadership experience. Join us to make a significant impact in community healthcare.
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:
Join us and make a lasting impact in community healthcare. We would love to hear from you!
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 able & willing to work across a 7 day service.
Livewell Southwest is an independent, award-winning socialenterprise 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, sportscentres, 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 programs, 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.
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.
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 RangeThe 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 ResponsibilitiesClinical PracticeManage 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.
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 (PSIRF) processes, ensuring lessons are learned and shared.
Support a culture of continuous improvement, encouraging innovation, service redesign and clinical excellence.
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.
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.
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.
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.
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.
Participate in clinical audit, evaluation, and quality improvement initiatives using research methodology.
Contribute to or lead service-based research projects, disseminating findings to improve practice.
Maintain awareness of current research, innovations, and national guidance relevant to the specialty.
Take reasonable care for own health and safety and that of others in the workplace.
Adhere to infection prevention and control, manual handling, lone working, and safeguarding procedures.
Report and document all incidents, hazards, and near misses promptly via appropriate channels.
Participate in mandatory training and ensure compliance with organisational policies and procedures.
Undertake physical intervention and Basic Life Support training where required for the role.
Demonstrate a clear understanding of safeguarding adults and children policies, reporting concerns in line with statutory guidance.
Promote equality, diversity and inclusion, respecting the rights and dignity of all patients and staff.
Support carers and families, acting as an advocate for patients needs and preferences.
Support Livewell Southwests commitment to reducing carbon emissions and promoting environmentally sustainable healthcare practices.
Contribute to waste reduction, low‑carbon travel, and efficient use of resources.
Undertake moderate physical activity daily, including manual handling, use of equipment and travel between patient homes.
Work within unpredictable environments, dealing with emotional and distressing circumstances such as end‑of‑life care, safeguarding, and crisis management.
Maintain concentration when managing complex caseloads, drug calculations, and critical decision‑making.
Adapt to changing priorities while ensuring high standards of care and documentation.
Patients, families, and carers
General Practitioners and Practice Nurses
Social Services and Community Mental Health Teams
Acute and Community Hospital colleagues
Allied Health Professionals and Voluntary Sector Partners
Clinical Operational Managers and Service Leads
External agencies and safeguarding partners
The post holder will maintain professional, effective communication across all levels of the organisation and with external stakeholders, contributing to collaborative, integrated, and person-centred service delivery.
This post is subject to the Rehabilitation of Offenders Act (Exceptions Order) 1975 and as such it will be necessary for a submission for Disclosure to be made to the Disclosure and Barring Service (formerly known as CRB) to check for any previous criminal convictions.
Full-time,Part-time,Job share,Flexible working