Frailty Nurse

Ringmead Medical Group; Bracknell; On-site; GBP 42,000 - 54,000; Full time

Benefits offered by this job

Birthday leave

Supportive environment

Clinical mentorship

Service development opportunities

Job summary

Ringmead Medical Group in Bracknell is seeking a Frailty Nurse to lead structured care home ward rounds and proactive reviews for elderly residents. The role includes in-practice frailty reviews and remote consultations, with strong MDT support and governance involvement.

You will work closely with the Frailty & Care Home Lead GPs, attend regular MDT meetings, and contribute to QOF achievement and service development. A non-medical prescribing qualification is desirable but not essential.

Qualifications

• Comprehensive clinical assessment and diagnostic skills.
• Safe, evidence-based clinical decision-making.
• Ongoing evaluation and review of care.
• Ability to work autonomously and within a team.
• Experience caring for frail, elderly or housebound patients.
• Strong communication and interpersonal skills.
• Experience contributing to QOF achievement.
• Experience participating in MDT working.
• Experience using EMIS Web is preferred.

Responsibilities

• Undertake comprehensive history taking and physical assessment.
• Diagnose and manage acute and chronic conditions within scope of practice.
• Conduct regular, structured care home ward rounds (primary component of role).
• Review new care home residents and manage acute presentations.
• Lead long-term condition management for frail and elderly patients.
• Provide remote consultations where clinically appropriate.
• Contribute to anticipatory care planning and personalised care discussions.
• Maintain high-quality documentation and coding.
• Participate in audit and quality improvement initiatives.
• Engage in multidisciplinary teamwork and governance.

Skills

NMC Registration

Frailty assessment

Clinical assessment

Autonomous with team

Communication skills

Triage & safe decisions

Primary care / care home experience

QOF experience

MDT collaboration

Education

NMC registration

Tools

EMIS Web

Job description

This role is centred on structured care home ward rounds and proactive care home reviews - this will form the core and majority of the workload.

You will:

• Conduct regular care home ward rounds
• Review new care home residents
• Manage acute presentations within care homes
• Lead long-term condition management for frail residents
• Support QOF work relating to care home patients

In addition to care home rounds, the role will also include:

• In-practice frailty reviews for patients attending appointments
• Remote consultation frailty reviews where appropriate

You will work closely with the Frailty & Care Home Lead GPs and be supported by a comprehensive, well-established MDT. The role includes attendance at regular MDT meetings, educational sessions and governance meetings.

This is a varied, autonomous and highly rewarding role for a clinician who enjoys proactive medicine, structured frailty care and multidisciplinary collaboration.

Non-Medical Prescribing is desirable but not essential.

• Birthday day off in addition to annual leave entitlement
• Supportive and forward-thinking working environment
• Strong clinical mentorship and MDT support
• Opportunities for service development and innovation

Main duties of the job

Applicants should be experienced clinical practitioners who, acting within professional boundaries, will provide:

• Comprehensive clinical assessment
• Diagnosis and treatment
• Safe, evidence-based clinical decision-making
• Ongoing evaluation and review of care

The post holder will:

• Demonstrate strong assessment and diagnostic skills
• Prioritise and triage patient needs effectively
• Escalate appropriately when required
• Work collaboratively within the MDT
• Maintain high-quality documentation and coding
• Contribute to chronic disease management and QOF achievement

The workload is structured and purposeful, with care home rounds forming the main focus of the role.

About us

Ringmead is a 5-site training practice looking after approximately 40,000 patients across Bracknell, Crowthorne, Sandhurst and Owlsmoor. As well as delivering excellent primary care, we are fortunate in having clinicians with expertise in cardiology, haematology, palliative care, immunology, dermatology, minor surgery, joint injections, LARCs and frailty. There is a strong ethos on supporting one another, as well as on education. We offer protected educational and clinical meetings several times a month and mentor ST and FY doctors, medical students, nursing students and pharmacy students. We are also highly active within our ICB, Federation and PCN (The Health Triangle) with 2 of our Partners being the Clinical Directors.

Job responsibilities

Key Responsibilities

1. Clinical Responsibilities

The post holder will:

• Undertake comprehensive history taking and physical assessment
• Diagnose and manage acute and chronic conditions within scope of practice
• Conduct regular, structured care home ward rounds (primary component of role)
• Review new care home residents
• Manage acute presentations within care homes
• Lead long-term condition management for frail and elderly patients
• Contribute to anticipatory care planning and personalised care discussions
• Provide remote consultations where clinically appropriate
• Deliver in-practice frailty reviews for patients attending appointments
• Recognise professional limitations and elevate appropriately to GP or MDT colleagues
• Maintain accurate, contemporaneous and high-quality clinical records

2. Care Home & Frailty Service Delivery

• Build effective working relationships with care home staff
• Ensure medical queries are reviewed promptly and safely
• Support safe medicines optimisation in collaboration with pharmacists and GPs
• Contribute to reducing avoidable admissions and improving continuity of care
• Participate in service development and refinement of frailty pathways

3. QOF & Quality Improvement

The Frailty Nurse will:

• Support QOF-related work for care home patients
• Contribute to chronic disease reviews and monitoring
• Ensure accurate clinical coding and documentation
• Participate in audit and quality improvement initiatives
• Contribute to governance discussions and service evaluation

4. Multidisciplinary Working

• Work collaboratively within a comprehensive and well-established MDT
• Liaise closely with the Frailty & Care Home Lead GPs
• Attend regular MDT meetings
• Participate in clinical governance and educational meetings
• Contribute to coordinated, team-based patient care

5. Professional Responsibilities

• Maintain active NMC registration
• Work within professional scope of practice and competencies
• Demonstrate safe, evidence-based clinical decision-making
• Engage in continuous professional development
• Maintain revalidation requirements
• Uphold confidentiality, safeguarding and data protection standards

Person Specification

Qualifications

• Registered Nurse (NMC)
• Experience managing frail, elderly or housebound patients
• Strong clinical assessment and diagnostic skills
• Ability to work autonomously and within a team
• Excellent communication and interpersonal skills
• Ability to prioritise, triage and make safe clinical decisions
• Experience working in primary care and or care home settings
• Experience contributing to QOF achievement
• Experience participating in MDT working
• Experience using EMIS Web clinical system

Disclosure and Barring Service Check

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.