PCN Frailty Nurse

Job description

Job responsibilities

The Health Triangle PCN- Frailty Nurse Job Description

Job Title

Frailty Nurse

Employer

Health Triangle Primary Care Network

Practices

Ringmead Medical Group, Evergreen Surgery, Crownwood Medical Practice

Reports To

Clinical: Frailty Lead GP

Administration: PCN Manager

Job Purpose

The Frailty Nurse will play a central role in delivering high-quality, proactive, and patient-centred care to frail, elderly and housebound patients across Health Triangle PCN.

The core focus of the role is the delivery of structured care home ward rounds and proactive clinical oversight across the care homes within the PCN. The post holder will also support frailty reviews within practice, undertake home visits where appropriate, and provide remote consultations.

The role aims to improve outcomes for frail patients, reduce avoidable hospital admissions, optimise long-term condition management, and support quality improvement across the network.

Key Responsibilities

1. Clinical Responsibilities

The post holder will:

• Undertake comprehensive history taking and physical assessment
• Diagnose and manage acute and chronic conditions within scope of practice
• Conduct regular, structured care home ward rounds (primary component of role)
• Review new care home residents
• Manage acute presentations within care homes
• Lead long-term condition management for frail and elderly patients
• Ensure that all eligible residents in aligned care homes are identified and offered both seasonal and routine vaccinations
• Contribute to anticipatory care planning and personalised care discussions
• Provide remote consultations where clinically appropriate
• Deliver in-practice frailty reviews for patients attending appointments
• Recognise professional limitations and escalate appropriately to GP or MDT colleagues
• Maintain accurate, contemporaneous and high-quality clinical records in GP clinical system

2. Care Home & Frailty Service Delivery

• Provide consistent clinical oversight to PCN care homes
• Build effective working relationships with care home staff
• Ensure medical queries are reviewed promptly and safely
• Support safe medicines optimisation in collaboration with pharmacists and GPs
• Contribute to reducing avoidable admissions and improving continuity of care
• Participate in service development and refinement of frailty pathways

3. QOF & Quality Improvement

The Frailty Nurse will:

• Support QOF-related work for care home patients
• Contribute to chronic disease reviews and monitoring
• Ensure accurate clinical coding and documentation
• Participate in audit and quality improvement initiatives
• Contribute to governance discussions and service evaluation

4. Multidisciplinary Working

• Work collaboratively within a comprehensive and well-established MDT
• Liaise closely with the Frailty & Care Home Lead GPs
• Attend regular MDT meetings
• Participate in clinical governance and educational meetings
• Contribute to coordinated, team-based patient care

5. Professional Responsibilities

• Maintain active NMC registration
• Work within professional scope of practice and competencies
• Demonstrate safe, evidence-based clinical decision-making
• Engage in continuous professional development
• Maintain revalidation requirements
• Uphold confidentiality, safeguarding and data protection standards

Person Specification

Essential

• Registered Nurse (NMC)
• Experience managing frail, elderly or housebound patients
• Strong clinical assessment and diagnostic skills
• Ability to work autonomously and within a team
• Excellent communication and interpersonal skills
• Ability to prioritise, triage and make safe clinical decisions
• Access to car and clean driving license

Desirable

• Non-Medical Prescribing qualification
• Experience working in primary care and/or care home settings
• Experience contributing to QOF achievement
• Experience participating in MDT working
• Experience using EMIS Web clinical system

Terms & Benefits

• 0.75 WTE (approximately 2830 hours per week)
• Competitive salary (pro rata)
• Private healthcare scheme
• Birthday day off in addition to annual leave entitlement
• Supportive and forward-thinking working environment
• Strong clinical mentorship and MDT support
• Opportunities for service development and innovation

Person Specification

Experience

Essential

• Experience managing frail, elderly or housebound patients
• Strong clinical assessment and diagnostic skills
• Ability to work autonomously and within a team
• Excellent communication and interpersonal skills
• Ability to prioritise, triage and make safe clinical decisions
• Access to car and clean driving license

Desirable

• Experience working in primary care and/ or care home settings
• Experience contributing to QOF achievement
• Experience participating in MDT working
• Experience using EMIS Web Clinical System

Qualifications

Essential

• NMC Registration

Desirable

• Non-medical prescribing

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).

Employer details

Employer name

Ringmead Medical Practice

Address

Birch Hill Medical Centre

Leppington

Bracknell

Berkshire

RG12 7WW

Employer's website

https://www.ringmeadmedicalpractice.org.uk/ (Opens in a new tab)