Frailty Nurse

Testvale Surgery; Liss Forest; On-site; GBP 34,000 - 52,000; Full time

Job summary

Totton Primary Care Network is seeking an experienced Frailty Nurse to join our multidisciplinary team, supporting proactive, high-quality care for frail and elderly patients. You will contribute to early identification, personalised care planning, and coordinated care across primary, community, and secondary services.

The role emphasizes comprehensive frailty assessments, care planning with patients and carers, and ongoing monitoring of frail individuals within a busy PCN setting.

Qualifications

• Registered Nurse with current NMC registration.
• Experience with older adults and/or frailty.
• Experience in clinical assessment and care planning.
• Experience in primary care or community settings.
• Strong assessment and decision-making skills.
• Knowledge of frailty, long-term conditions and proactive care.
• Autonomous working and caseload management.
• Excellent communication and teamwork.

Responsibilities

• Undertake comprehensive frailty assessments including clinical, functional, psychological, and social aspects of care.
• Develop, implement and regularly review personalised care plans with patients, carers and the MDT.
• Provide clinical reviews and ongoing monitoring for moderately or severely frail patients.
• Support admission avoidance through early intervention and care coordination.
• Contribute to anticipatory and end-of-life care planning where appropriate.
• Work closely with GPs, ANPs, Care Coordinators, Social Prescribers, pharmacists, and community teams.
• Participate in MDT meetings and proactive care planning forums.
• Act as a clinical resource for frailty within the PCN.
• Liaise with secondary care and community services to ensure seamless pathways.
• Contribute to development and delivery of PCN frailty services per DES requirements.

Skills

Clinical assessment

Care planning

Frailty care

Autonomous working

Team collaboration

IT literacy

Communication

Travel between sites

Education

NMC registered Nurse

Current NMC registration

Degree-level qualification or equivalent

Non-medical prescribing qualification

Tools

EMR systems

Job description

Job summary

Totton Primary Care Network is seeking an experienced and motivated Frailty Nurse to join our multidisciplinary team, supporting the delivery of proactive, high-quality care to our frail and elderly population.

We have an exciting opportunity for an experience Frailty Nurse to join our established Primary Care Network (PCN). We serve the people of Totton and surrounding areas, including the outer parts of the New Forest, with a population of approximately 37,000 patients. We are an expanding and progressive organisation with excellent patient care as our central value. We are seeking to expand our care and support the delivery of pro-active, high quality care to our patients. This role is central to improving outcomes for patients living with frailty through early identification, personalised care planning, and coordinated working across primary, community, and secondary care services.

Main duties of the job

• Undertake comprehensive frailty assessments, including clinical, functional, psychological, and social aspects of care.
• Develop, implement, and regularly review personalised care and support plans in collaboration with patients, carers, and the wider MDT.
• Provide clinical reviews and ongoing monitoring for patients identified as moderately or severely frail.
• Support admission avoidance through early intervention, escalation planning, and coordination with community and acute services.
• Contribute to anticipatory care planning, including end-of-life and advance care planning where appropriate.

Work closely with GPs, ANPs, Care Coordinators, Social Prescribers, pharmacists, and community teams.

• Participate in MDT meetings, case discussions, and proactive care planning forums.
• Act as a clinical resource for frailty-related advice within the PCN.
• Liaise with secondary care, community services, and voluntary sector organisations to ensure seamless care pathways.

Contribute to the development and delivery of PCN frailty services in line with DES requirements.

• Support quality improvement initiatives related to frailty and proactive care.
• Ensure accurate and timely clinical documentation in patient records.
• Maintain awareness of current best practice, guidelines, and evidence relating to frailty care.

About us

We have an exciting opportunity for an experience Frailty Nurse to join our established Primary Care Network (PCN). We serve the people of Totton and surrounding areas, including the outer parts of the New Forest, with a population of approximately 37,000 patients.

Job responsibilities

Key Responsibilities

Clinical Responsibilities

• Undertake comprehensive frailty assessments, including clinical, functional, psychological, and social aspects of care.
• Develop, implement, and regularly review personalised care and support plans in collaboration with patients, carers, and the wider MDT.
• Provide clinical reviews and ongoing monitoring for patients identified as moderately or severely frail.
• Support admission avoidance through early intervention, escalation planning, and coordination with community and acute services.
• Contribute to anticipatory care planning, including end-of-life and advance care planning where appropriate.

Multidisciplinary & Collaborative Working

• Work closely with GPs, ANPs, Care Coordinators, Social Prescribers, pharmacists, and community teams.
• Participate in MDT meetings, case discussions, and proactive care planning forums.
• Act as a clinical resource for frailty-related advice within the PCN.
• Liaise with secondary care, community services, and voluntary sector organisations to ensure seamless care pathways.

Service Development & Quality

• Contribute to the development and delivery of PCN frailty services in line with DES requirements.
• Support quality improvement initiatives related to frailty and proactive care.
• Ensure accurate and timely clinical documentation in patient records.
• Maintain awareness of current best practice, guidelines, and evidence relating to frailty care.

Professional Responsibilities

• Maintain NMC registration and adhere to the NMC Code of Professional Conduct.
• Take responsibility for own professional development and mandatory training.
• Participate in clinical supervision, appraisal, and revalidation processes.
• Work within PCN policies, procedures, and governance frameworks.

Person Specification

Qualifications

Essential

• Registered Nurse with current NMC registration
• Experience working with older adults and/or patients living with frailty
• Experience of clinical assessment and care planning
• Experience working within primary care, community services, or a similar healthcare setting
• Strong clinical assessment and decision-making skills
• Knowledge of frailty, long-term conditions, and proactive care approaches
• Ability to work autonomously and manage a clinical caseload
• Excellent communication and interpersonal skills
• Ability to work collaboratively within a multidisciplinary team
• Good IT skills and ability to maintain accurate clinical records
• Organised, flexible, and adaptable approach to work
• Patient-centred and compassionate care approach
• Ability to manage workload effectively and prioritise competing demands
• Commitment to equality, diversity, and inclusion
• Willingness to travel between PCN sites as required
• Commitment to ongoing professional development
• Disclosure and Barring Service (DBS) check
• Occupational Health clearance
• Hold a valid driving licence with own car and business insurance to use for home visits.
• Experience of proactive or anticipatory care
• Experience working with care homes or long-term conditions
• Experience of working within a PCN or MDT setting
• Degree-level qualification or equivalent experience
• Non-medical prescribing qualification or willingness to work towards
• Knowledge of PCN structures and DES requirements
• Understanding of population health and personalised care

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.

UK Registration

Applicants must have current UK professional registration. For further information please see NHS Careers website (opens in a new window).

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. Applicants must have current UK professional registration.