LTC Nurse & ACP - Proactive Community Care

Bridgwater Bay Primary Care Network; Bridgwater; On-site; GBP 42,000 - 60,000; Full time

Job summary

Bridgwater Bay Primary Care Network is seeking an experienced Long-term condition nurse/ACP to lead anticipatory, personalised care for patients with LTCs and frailty in community and care home settings.

You will manage conditions such as diabetes, COPD and heart failure, coordinate holistic assessments, and collaborate with an integrated MDT to reduce deterioration and admissions. Autonomy in clinical decision-making and strong IT skills are essential.

Qualifications

• Registration with the NMC is essential.
• Experience in managing long-term conditions and frailty.
• Ability to work effectively within a multidisciplinary team.
• Non-medical prescriber status is preferred.

Responsibilities

• Identify and stratify frailty using validated tools (e.g. eFI).
• Conduct comprehensive biopsychosocial assessments including cognition and mobility.
• Apply specialist knowledge in long-term conditions (e.g. diabetes, COPD, cardiovascular).
• Develop and review personalised care and support plans with patients and families.
• Monitor for early deterioration and intervene to prevent crises.
• Facilitate advance care planning, DNACPR discussions, and end-of-life coordination.
• Collaborate with care home staff, community matrons, and MDTs.
• Contribute to integrated neighbourhood team (INT) working.

Skills

LTC management

Nurse/ACP

MDT collaboration

Education

NMC registration

Job description

Bridgwater Bay Primary Care Network is seeking an experienced Long-term condition nurse/ACP to lead anticipatory, personalised care for patients with LTCs and frailty in community and care home settings.

You will manage conditions such as diabetes, COPD and heart failure, coordinate holistic assessments, and collaborate with an integrated MDT to reduce deterioration and admissions. Autonomy in clinical decision-making and strong IT skills are essential.