PCN/INT Frailty Nurse

Nuneaton and Bedworth Primary Care Network; Nuneaton; Hybrid; GBP 52,000 - 54,000; Full time

Job summary

Nuneaton & Bedworth Primary Care Network is recruiting 2 Frailty Nurses to join the Integrated Neighborhood Teams across Nuneaton & Bedworth. The new role focuses on proactively identifying, assessing and managing frailty in the community to reduce hospital admissions and improve coordinated care for older patients.

You will work within multidisciplinary teams, liaising with GPs, care homes and social care, and you must be an NMC-registered nurse with Level 7 frailty qualification and a valid

Qualifications

• Registered Nurse with current NMC registration.
• Level 7 Frailty qualification.
• Experience with frail, elderly or complex patients in community settings.
• Experience presenting at MDT meetings.
• Experience in general practice and care homes.

Responsibilities

• Proactively identify patients with moderate to severe frailty and perform CGA.
• Develop, document and review personalised care plans with patients and carers.
• Identify patients at risk of hospital admission and intervene.
• Support advance care planning and end-of-life discussions with GP input.
• Deliver weekly care home ward rounds and liaise with care home staff.
• Coordinate MDT input and follow-up actions with services.

Skills

Frailty care

MDT collaboration

Community nursing

Car driver

Education

NMC registered nurse

Level 7 Frailty qualification

Job description

Go back Nuneaton & Bedworth Primary Care Network

PCN/INT Frailty Nurse

The closing date is 01 November 2026

We are excited to be recruiting 2 Frailty Nurses to join our PCN to support the 2 Integrated Neighborhood Teams across Nuneaton & Bedworth.

This is a brand new role that is intended to work as part of our Multi-Disciplinary Teams to proactively identify, assess and manage patients living with frailty - to support the INT agenda.

The role is designed to reduce avoidable hospital admissions, improve continuity of care for frail and elderly patients, and strengthen coordination between general practice, care homes and the wider community and social care services.

Main duties of the job

As this is a new role, it is anticipated that the role will develop and grow over time.

Primary Care is also in a place of transition with the introduction of Integrated Neighborhood Teams, and the anticipated evolution of Primary Care Networks into INTs.

This is a really exciting opportunity for us to drive how these initiatives are developed and delivered.

It is anticipated that you will work with colleagues across Primary Care, Secondary Care, Social Services and Local Authorities to support our moderate and severely frail patients to reduce A&E attendances and hospital admissions.

About us

We are a large PCN incorporating 11 member practices across Nuneaton and Bedworth. We are supporting 2 INTs (Nuneaton and Bedworth & Bulkington), which represent patients from 19 local practices.

We have a dynamic and supportive PCN Board, and an established Senior Management Team that work really well together to develop ideas and initiatives for new ways of working to support our workforce and patient population.

We are currently developing a management team to support the delivery of INT requirements, which will include leads for Frailty, Care Homes, End of Life and MDT working to ensure that the services we are delivering for our patients is the best it can be.

We have a significant workforce of about 75 staff working across the PCN and supporting our Enhanced Access service. We pride ourselves on the fact that we have a very small turnover of staff, which is indicative of how much our staff are valued and supported and the culture of our PCN.

Job responsibilities

Main Responsibilities

These responsibilities are for an identified cohort of patients.

Clinical Care

• Proactively identify patients with moderate to severe frailty using recognised frailty indices and practice registers
• Undertake comprehensive geriatric assessments (CGA), including functional, cognitive, social, and medication review
• Develop, document, and regularly review personalised care and support plans in partnership with patients, families and carers
• Identify patients at risk of unplanned hospital admission and initiate proactive interventions to reduce that risk
• Support patients and families with advance care planning discussions, including ReSPECT forms and end-of-life wishes, escalating to GPs or specialist palliative services as appropriate
• Recognise and respond appropriately to signs of clinical deterioration, escalating to GPs or emergency services where necessary

Care Home Ward Rounds

• Deliver structured weekly ward rounds at designated care homes
• Review resident health status, medication, and care plans in collaboration with care home staff
• Liaise with GPs to action clinical decisions arising from ward rounds
• Build strong working relationships with care home managers and staff to support early identification of resident health concerns

Multidisciplinary Working

• Present complex and high‑risk frailty patients at the monthly INT MDT meeting, providing clinical summaries and care plan updates
• Coordinate input and follow‑up actions from MDT discussions across relevant services
• Work collaboratively with PCN Pharmacists, Social Prescribers, Care Coordinators and community teams to deliver joined‑up, patient‑centred care
• Act as a point of clinical liaison between general practice and community/social care services for frailty patients

Administration and Governance

• Maintain accurate, timely clinical records in line with practice and PCN information governance policies
• Contribute to PCN frailty data collection, audit, and outcome reporting
• Participate in relevant clinical audits and quality improvement initiatives
• Attend PCN and practice meetings as required

Professional Development

• Maintain NMC registration and up-to-date clinical competencies
• Participate in regular clinical supervision, appraisal, and revalidation processes
• Undertake training relevant to frailty, gerontology, and long‑term condition management

Keep up to date with national and local guidance relevant to frailty care (e.g. NICE, BGS, local ICB pathways)

Person Specification

Experience

• Experience working with frail, elderly or complex patients in community settings
• Experience presenting at or contributing to MDT meetings
• Experience of working in a general practice setting
• Experience of working in a care home setting

Personal Attributes

• Highly organised to manage workload
• Collaborative team player
• Driver with access to a car to be able to travel between sites, predominantly across Nuneaton and Bedworth

Qualifications

• Registered Nurse with current NMC registration
• Level 7 Frailty qualification

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.

Nuneaton & Bedworth Primary Care Network

£52,000 to £54,000 a yearUplift for Care Home Lead