Frailty Nurse - Proactive Elder Care Champion

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

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.