Job summary
Worcester City PCN is seeking an Advanced Clinical Practitioner to join our Care Home and Frailty services. The role focuses on delivering proactive, coordinated and personalised care for residents in care homes and adults living with moderate to severe frailty in the community. Working as part of a multidisciplinary team, the post holder will support delivery of the Enhanced Health in Care Homes (EHCH) framework through regular clinical reviews, structured medication reviews, proactive care planning, MDT collaboration, anticipatory care and timely response to deterioration.
The ACP will provide advanced assessment, diagnosis and management within their scope of practice, leading key elements of the frailty pathway including holistic assessment, MDT review, crisis prevention and follow up. The role also involves supporting personalised care planning, ReSPECT discussions and escalation planning, as well as delivering routine and urgent care for PCN-aligned care home residents alongside GP leads.
This position aims to reduce avoidable crises, A&E attendances and hospital admissions while improving quality of life for patients and carers. The post holder will ensure accurate documentation, contribute to governance and support continuous service improvement.
Main duties of the job
The post holder will work with a high level of autonomy and complex decision making, supported by a Masters level qualification across the four pillars of advanced practice. They will act as a clinical expert in frailty and care home medicine, providing accessible, high quality advanced clinical care.
The role includes leading advanced assessments for patients with complex or chronic conditions, including frailty assessment, risk stratification, and early identification of deterioration, enabling differential diagnosis and effective management plans.
Working within the PCN Care Home Team, the post holder will support delivery of the Enhanced Health in Care Homes (EHCH) framework through proactive care planning, MDT reviews and coordinated resident support. They will also contribute to the monthly Palliative Care MDT, offering advanced clinical input, shared decision making and escalation planning.
The ACP will provide routine and urgent clinical care for care home residents, respond to deterioration, and work closely with GP leads to ensure safe, effective practice. They will deliver timely reviews to prevent crises, including urgent assessments and home visits, helping to reduce avoidable A&E attendance and unplanned admissions.
The post holder will collaborate with clinical and nonclinical colleagues to build team capacity and improve continuity of care, and will participate in audit, service evaluation and quality improvement to support ongoing service development.
About us
About Vertis Health
We're a federation of GP surgeries and PCNs in Worcestershire, serving over 600,000 NHS patients through a variety of local services. Our community of GPs are our stakeholders, meaning we're powered by the community we've created- and our goal is to find ways to make it easier for them to spend less time and money on administrative workload, and more time with their patients.
Our GP surgeries remain independent, while keeping the benefits of being part of a larger organisation- and we exist to protect the interests of our members through advocacy, business support, and revenue generation.
We're ambitious about growth in our network- and so, our diversified services help our PCN store invest in vital local healthcare initiatives, providing a sustainable future for their communities in the long term.
Job description
Job responsibilities
Advanced Clinical Practitioner (ACP) Frailty & Care Home Team
Employer: Worcester City PCN
Base: St Martins Gate & Henwick Halt Medical Centre
Hours: Up to 30 hours per week
Salary: Band 8a (DOE)
Reports to: PCN Clinical Director & PCN Management Team
About the Role
Worcester City PCN is seeking an experienced Advanced Clinical Practitioner to deliver proactive, personalised and coordinated care for residents in PCN aligned care homes and for people living with moderate to severe frailty in the community.
The ACP will work as an autonomous, highly skilled clinician across the frailty and care home pathways, supporting the delivery of the Enhanced Health in Care Homes (EHCH) framework. The post holder will undertake advanced clinical assessments, diagnose and manage complex presentations, support crisis avoidance, and contribute to anticipatory and personalised care planning, including ReSPECT.
You will work closely with the multidisciplinary team (MDT) to improve outcomes, reduce avoidable admissions, and enhance quality of life for patients and carers.
Key ResponsibilitiesClinical Practice
- Provide advanced assessment, diagnosis, and management for patients with complex frailty or long term conditions.
- Conduct holistic frailty assessments using recognised tools (e.g., Rockwood CFS).
- Deliver routine and urgent clinical reviews for care home residents, responding promptly to deterioration.
- Undertake crisis avoidance activity, including rapid assessment and escalation when necessary.
- Request and interpret diagnostics within scope of practice.
- Independently prescribe (V300) and review medications following evidence based guidelines.
- Lead anticipatory care planning, including ReSPECT discussions and personalised escalation plans.
- Support safe discharge and stepdown planning with clear communication and documentation.
Multidisciplinary & System Working
- Participate in MDT meetings, including the monthly Palliative Care MDT.
- Liaise with GPs, pharmacists, paramedics, physician associates, community services and care home staff to ensure coordinated, safe care.
- Provide clinical advice and support to colleagues, contributing to a collaborative team culture.
Quality, Governance & Improvement
- Record all activity using PCN templates, frailty registers and systems.
- Participate in audit, evaluation and quality improvement to strengthen the PCN frailty pathway.
- Promote evidence based practice and support implementation of service developments.
Professional Responsibilities
- Maintain accurate clinical records in line with legislation and organisational policies.
- Adhere to NMC/HCPC standards, safeguarding responsibilities and professional codes.
- Engage fully with supervision, reflective practice and annual appraisal.
- Support training, education and mentorship of colleagues and learners.
Communication
- Communicate effectively and compassionately with patients, carers and MDT members.
- Adjust communication methods for individuals with cognitive, sensory or psychological needs.
- Support shared decision making and clear explanation of care plans and clinical findings.
Confidentiality, Equality & Diversity
- Maintain strict confidentiality regarding patient and organisational information.
- Uphold the rights, dignity and cultural needs of patients and colleagues.
- Support an inclusive, respectful working environment.
Benefits
- Band 8a salary (DOE)
- Weekly CPD time ( day, pro rata)
- Enhanced annual leave options and ability to purchase additional leave
- Paid volunteer days
- Enhanced parental leave package
- Mentorship, supervision and development opportunities
Job description
Job responsibilities
Advanced Clinical Practitioner (ACP) Frailty & Care Home Team
Employer: Worcester City PCN
Base: St Martins Gate & Henwick Halt Medical Centre
Hours: Up to 30 hours per week
Salary: Band 8a (DOE)
Reports to: PCN Clinical Director & PCN Management Team
About the Role
Worcester City PCN is seeking an experienced Advanced Clinical Practitioner to deliver proactive, personalised and coordinated care for residents in PCN aligned care homes and for people living with moderate to severe frailty in the community.
The ACP will work as an autonomous, highly skilled clinician across the frailty and care home pathways, supporting the delivery of the Enhanced Health in Care Homes (EHCH) framework. The post holder will undertake advanced clinical assessments, diagnose and manage complex presentations, support crisis avoidance, and contribute to anticipatory and personalised care planning, including ReSPECT.
You will work closely with the multidisciplinary team (MDT) to improve outcomes, reduce avoidable admissions, and enhance quality of life for patients and carers.
Key ResponsibilitiesClinical Practice
- Provide advanced assessment, diagnosis, and management for patients with complex frailty or long term conditions.
- Conduct holistic frailty assessments using recognised tools (e.g., Rockwood CFS).
- Deliver routine and urgent clinical reviews for care home residents, responding promptly to deterioration.
- Undertake crisis avoidance activity, including rapid assessment and escalation when necessary.
- Request and interpret diagnostics within scope of practice.
- Independently prescribe (V300) and review medications following evidence based guidelines.
- Lead anticipatory care planning, including ReSPECT discussions and personalised escalation plans.
- Support safe discharge and stepdown planning with clear communication and documentation.
Multidisciplinary & System Working
- Participate in MDT meetings, including the monthly Palliative Care MDT.
- Liaise with GPs, pharmacists, paramedics, physician associates, community services and care home staff to ensure coordinated, safe care.
- Provide clinical advice and support to colleagues, contributing to a collaborative team culture.
Quality, Governance & Improvement
- Record all activity using PCN templates, frailty registers and systems.
- Participate in audit, evaluation and quality improvement to strengthen the PCN frailty pathway.
- Promote evidence based practice and support implementation of service developments.
Professional Responsibilities
- Maintain accurate clinical records in line with legislation and organisational policies.
- Adhere to NMC/HCPC standards, safeguarding responsibilities and professional codes.
- Engage fully with supervision, reflective practice and annual appraisal.
- Support training, education and mentorship of colleagues and learners.
Communication
- Communicate effectively and compassionately with patients, carers and MDT members.
- Adjust communication methods for individuals with cognitive, sensory or psychological needs.
- Support shared decision making and clear explanation of care plans and clinical findings.
Confidentiality, Equality & Diversity
- Maintain strict confidentiality regarding patient and organisational information.
- Uphold the rights, dignity and cultural needs of patients and colleagues.
- Support an inclusive, respectful working environment.
Benefits
- Band 8a salary (DOE)
- Weekly CPD time ( day, pro rata)
- Enhanced annual leave options and ability to purchase additional leave
- Paid volunteer days
- Enhanced parental leave package
- Mentorship, supervision and development opportunities
Person Specification
Qualifications
Essential
- Registered Nurse/ Paramedic
- MSc in Advanced Clinical Practice
- Non- Medical Prescribing (V300) if within scope of professional practice
- Advanced Assessment Skills Module
- Current and valid certification
- Evidence of continuing Professional Development
- UK Driving licence
- 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.
Desirable
- Extensive experience working in the NHS
- Advanced clinical practice skills and clinical examination skills
- Management of patients with common acute medical conditions
- Experience of working with patients across a range of settings
- Experience of assessing and managing frailty in community settings, including housebound patients and/or care home residents (or demonstrable transferable experience).
Experience
Essential
- Knowledge of the role of Primary Care in the wider system and the potential role of federations within this.
Desirable
- Knowledge of frailty frameworks and proactive care approaches anticipatory care planning, ReSPECT) and local ageing well agendas.
- Knowledge of current national and local agendas particularly the Long-Term Plan.
- (e.g. 5Ms, Rockwood CFS, Knowledge of corporate, clinical and information governance and systems for managing particularly clinical governance.
- Management of patients with long-term conditions
Research and Development
Essential
- Acting as an expert resource, provide education and development opportunities for others.
- Develop own expert clinical knowledge and participate in the continuous development of self and others clinical knowledge, through supervision and mentorship, in conjunction with other health care professionals. Ensure own compliance with regard to mandatory training and advanced continuous professional development requirements for registration with the NMC / HCPC /.
- Develop evidence-based practice guidelines for care.
- Be able to implement research findings into practise including the use of and development of policies/protocols and guidelines. Be involved in audit and service evaluation.
Person Specification
Qualifications
Essential
- Registered Nurse/ Paramedic
- MSc in Advanced Clinical Practice
- Non- Medical Prescribing (V300) if within scope of professional practice
- Advanced Assessment Skills Module
- Current and valid certification
- Evidence of continuing Professional Development
- UK Driving licence
- 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.
Desirable
- Extensive experience working in the NHS
- Advanced clinical practice skills and clinical examination skills
- Management of patients with common acute medical conditions
- Experience of working with patients across a range of settings
- Experience of assessing and managing frailty in community settings, including housebound patients and/or care home residents (or demonstrable transferable experience).
Experience
Essential
- Knowledge of the role of Primary Care in the wider system and the potential role of federations within this.
Desirable
- Knowledge of frailty frameworks and proactive care approaches anticipatory care planning, ReSPECT) and local ageing well agendas.
- Knowledge of current national and local agendas particularly the Long-Term Plan.
- (e.g. 5Ms, Rockwood CFS, Knowledge of corporate, clinical and information governance and systems for managing particularly clinical governance.
- Management of patients with long-term conditions
Research and Development
Essential
- Acting as an expert resource, provide education and development opportunities for others.
- Develop own expert clinical knowledge and participate in the continuous development of self and others clinical knowledge, through supervision and mentorship, in conjunction with other health care professionals. Ensure own compliance with regard to mandatory training and advanced continuous professional development requirements for registration with the NMC / HCPC /.
- Develop evidence-based practice guidelines for care.
- Be able to implement research findings into practise including the use of and development of policies/protocols and guidelines. Be involved in audit and service evaluation.
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).
Additional information
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).
