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A healthcare provider in Skegness is looking for an experienced nurse to support frail older patients within a multidisciplinary team. This role includes conducting assessments, developing care plans, and collaborating with healthcare professionals. Candidates should have a relevant professional qualification and 5 years of post-registration experience. This position offers the opportunity to make a significant impact on patient well-being.
An exciting opportunity has become available for an enthusiastic and forward-thinking experienced nurse with extended skills to join the First Coastal PCN in a role that will be developed as it progresses. This role will focus heavily on working with our frail and older people.
The successful candidate will be joining our Primary Care Community team, working with GPs, Therapy and Nursing Teams, Pharmacist, Care Co‑Ordinators, Health and Wellbeing Coaches and Social Prescribing Link Workers.
Interviews are scheduled to take place on Thursday 27th November 2025
This role will focus on -
Assessing and supporting our complex, frail older people, supporting a proactive, patient‑centred approach and acute presentations as they arise.
Supporting our patients and both informal and formal carers to avoid crises and hospital admissions and to stay well in their own home or preferred care setting wherever and whenever possible.
Support patients with complex health care needs.
Carrying out assessments predominantly in patients’ place of residence.
Provide clinically effective, person‑centred and evidence‑based assessment and undertake anticipatory and personalised care planning and intervention to our patients.
Provide support and share information and care planning with colleagues to support escalation and care/treatment planning.
Be able to have and develop skills in advance care planning.
First Coastal PCN covers a population of approximately 84,000 patients and is made up of seven practices: Marsico Medical Practice (Mablethorpe), Hawthorn Medical Practice (Skegness), Beacon Medical Practice (Skegness), Merton Lodge (Alford), Spilsby Surgery, Stickney Surgery and Old Leake Medical Practice. These practices work together across coastal and rural areas to deliver care to the local population.
Take referrals from as agreed in the standard operating plan.
Undertake and contribute to ongoing Comprehensive Geriatric Assessment.
Assess, plan, implement and evaluate treatment plans with an aim to increase independence to prevent or delay the need for care and support.
Work with patients, carers and informal carers to plan realistic, outcome‑focused goals.
Effectively manage a caseload of patients as part of a multi‑disciplinary team (MDT) providing specialist and evidence‑based assessment and interventions to patients in both a stable and acute phase of their condition, ensuring the physical, psychosocial, behavioural, perceptual, cognitive, sensory and environmental needs of patients are addressed.
Utilise specialist knowledge and clinical reasoning to plan and provide clinical interventions in consultation with other colleagues in the MDT and to work in a range of settings as appropriate (eg patients home or other community setting).
Adopt a patient‑centred and sensitive approach to care, collaborating with patients (and/or carers where appropriate) in all aspects of the outcomes of the assessment, planning, intervention, evaluation, reporting.
Work as part of a multi‑disciplinary community team to support patients effectively.
Using advance communications skills, be able to have advance care planning discussions and facilitate others to be able to start advance care planning conversations.
Engage with community partners enabling patients to access social activities to enhance their health and well‑being, and to ensure effective, safe care.
Work collaboratively with significant stakeholders.
Manage your own caseload and contribute to service development through co‑production.
Assist in the quality and activity monitoring systems to support evaluation of the effectiveness of the service.
Assist in the maintenance and development of the EHCH service for the PCN.
Attend practice meetings of the member practices if required, as well as Core Group Meetings (Community MDTs etc).
Prepared to attend further training courses and supervision sessions as required.
Provide training to the member practices on relevant therapies or interventions if required and as appropriate.
As this is a new and evolving role, this is not an exhaustive list of duties and responsibilities, and the post holder may be required to undertake other duties that fall within the grade of the job, in discussion with their line manager.
The content of this job description will be reviewed regularly in the light of changing service requirements and any such changes will be discussed with the post holder.
To support the PCN Clinical Director(s) and Board in setting and realising the vision, mission and business strategy of First Coastal PCN.
To play a role in the delivery of high‑quality primary health care services.
Maintain a working relationship with local health care providers in order to enable service delivery of mutual benefit and build a network and knowledge of referral routes to and from service providers.
To establish and maintain effective liaison with stakeholders including health, voluntary, social and education resources, attending relevant meetings as necessary.
Liaise with the Care Co‑Ordinator to refer people and/or introduce them to appropriate organisations locally and nationally where appropriate, eg voluntary, statutory (local authority) and local NHS organisations.
Support the PCN Manager in providing KPI reports for submission as requested.
Be responsible for the organisation and planning of own workload to meet set deadlines.
Follow PCN and practice policies and procedures as appropriate.
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.