Job summary
An exciting opportunity has arisen for an experienced and motivated nurse to join our newly established Primary Care Network Frailty Team as a Band 6 equivalent Frailty Nurse. This is an excellent time to join the service as it continues to grow and shape its model of care.
We are seeking a highly motivated and passionate individual with a strong interest in frailty care, committed to improving outcomes and enhancing quality of life for older people living with frailty. The successful candidate will demonstrate enthusiasm for delivering person-centred, proactive care and working collaboratively within a multidisciplinary team to provide high-quality, holistic support. The role will also contribute to the delivery of the Network Contract Local Enhanced Service (LES) requirements and support the ongoing development of high-quality frailty pathways across the PCN.
The post holder will play a key role in delivering proactive, person-centred care to patients living with mild frailty and those presenting with frailty syndromes. The role will focus on undertaking frailty assessments and structured Year of Care reviews within patients homes, working as part of the Frailty Team under the supervision of the Frailty Advanced Nurse Practitioner. The post holder will support early identification of risk, prevention of deterioration, and improved patient outcomes.
Main duties of the job
Key Responsibilities
* Undertake frailty assessments encompassing physical, psychological, functional, and social domains.
* Deliver structured Year of Care reviews for housebound patients, ensuring holistic, person-centred care planning.
* Assess and manage patients presenting with frailty syndromes, including falls, immobility, delirium, incontinence, and polypharmacy.
* Develop, implement, and regularly review personalised care plans in partnership with patients, carers, and the multidisciplinary team.
* Support advanced care planning, anticipatory care, and self-management education to promote independence and prevent deterioration.
* Recognise early signs of clinical deterioration, initiate appropriate interventions, and escalate concerns in line with local pathways and professional accountability.
* Work autonomously across multiple GP practices within the PCN, liaising effectively with community, voluntary, and secondary care services.
* Participate in and, where appropriate, lead Frailty MDT meetings to coordinate patient care and support shared decision-making.
* Contribute to service development, audit, quality improvement initiatives, and the ongoing evaluation of the Frailty Team model.
* Provide clinical guidance, supervision, and support to junior staff and lower band team members.
* Support the Frailty Team Lead in the delivery, coordination, and ongoing development of the Frailty Service.
About us
We are a network of six GP practices located in the west of Newcastle upon Tyne, brought together to form the Outer West Primary Care Network (PCN).
The practices in the Outer West have a strong history of working collaboratively, formalised through the creation of the PCN in 2019 as part of NHS Englands focus on delivering care tailored to local communities. The PCN provides a range of services to patients registered at its member practices, supporting proactive, coordinated, and person-centred care across the local population.
As part of its commitment to supporting older patients, the PCN has recently established a Frailty Team, focused on early identification, proactive management, and holistic care for people living with frailty. The team works across all six practices, fostering collaboration, sharing expertise, and developing innovative frailty pathways to improve outcomes and quality of life for this patient group.
Details
Date posted
24 February 2026
Pay scheme
Other
Salary
Depending on experience Band 6 Equivalent
Contract
Permanent
Working pattern
Part-time, Flexible working
Reference number
A
Job locations
Denton Park Health Centre
West Denton Way
Newcastle Upon Tyne
NE5 2QW
Job description
Job responsibilities
Patient Care & Clinical Management:
* Undertake holistic frailty assessments, including history taking and simple investigations
* Recognise and act on situations potentially detrimental to patient health and well being.
* Provide ongoing management of long-term conditions such as diabetes, COPD, hypertension, and cardiovascular disease.
* Support and advise patients on health promotion, illness prevention, and self-management.
* Support in the development of Advance Care Planning
* Deliver nursing treatments in collaboration with GPs or independently within agreed protocols.
* Perform health screenings within agreed protocols, referring to GPs as necessary.
* Provide appropriate signposting to other clinicians or external organisations while ensuring ongoing care.
* Ensure proactive and early case management to prevent unnecessary hospital admissions/readmissions.
* Maintain accurate documentation within GP online systems (EMIS, SystemOne).
* Communicate complex or sensitive information effectively to patients and carers, recognising barriers to understanding.
* Maintain effective communication with GP practices and other healthcare teams.
Team & Service Development:
* Support and guide HCAs and SPLWs as required.
* Contribute to the development and continual improvement of the PCN Frailty Team.
* Ensure care is evidence-based and aligns with local policies and procedures.
* Maintain professional competency and remain up to date for NMC revalidation.
In addition to the primary responsibilities, the frailty nurse may be requested to:
Participate in audit work, effectively utilising the audit cycle
Participate in local initiatives to enhance service delivery and patient care
Support and participate in shared learning within the practice
Continually review clinical practices, responding to local and national policies and initiatives where appropriate
Participate in the review of significant and near-miss events applying a structured approach, i.e. root cause analysis (RCA)
Job description
Job responsibilities
Patient Care & Clinical Management:
* Undertake holistic frailty assessments, including history taking and simple investigations
* Recognise and act on situations potentially detrimental to patient health and well being.
* Provide ongoing management of long-term conditions such as diabetes, COPD, hypertension, and cardiovascular disease.
* Support and advise patients on health promotion, illness prevention, and self-management.
* Support in the development of Advance Care Planning
* Deliver nursing treatments in collaboration with GPs or independently within agreed protocols.
* Perform health screenings within agreed protocols, referring to GPs as necessary.
* Provide appropriate signposting to other clinicians or external organisations while ensuring ongoing care.
* Ensure proactive and early case management to prevent unnecessary hospital admissions/readmissions.
* Maintain accurate documentation within GP online systems (EMIS, SystemOne).
* Communicate complex or sensitive information effectively to patients and carers, recognising barriers to understanding.
* Maintain effective communication with GP practices and other healthcare teams.
Team & Service Development:
* Support and guide HCAs and SPLWs as required.
* Contribute to the development and continual improvement of the PCN Frailty Team.
* Ensure care is evidence-based and aligns with local policies and procedures.
* Maintain professional competency and remain up to date for NMC revalidation.
In addition to the primary responsibilities, the frailty nurse may be requested to:
Participate in audit work, effectively utilising the audit cycle
Participate in local initiatives to enhance service delivery and patient care
Support and participate in shared learning within the practice
Continually review clinical practices, responding to local and national policies and initiatives where appropriate
Participate in the review of significant and near-miss events applying a structured approach, i.e. root cause analysis (RCA)
Person Specification
Qualifications
Essential
* Registered Nurse (Adult) with valid NMC registration
* Clinical skills qualification
Desirable
* Non-medical prescribing qualification or willingness to work towards
* Post-registration qualification in frailty, older peoples care, or long-term conditions management
Experience
Essential
* Minimum of 2 years post registration experience in primary or community care
* Post-registration experience working with older people and/or patients living with frailty
* Experience delivering Year of Care reviews
* Experience managing patients with long-term conditions and complex needs
* Experience of holistic assessment and care planning
* Strong communication and consultation skills.
* Ability to work autonomously and collaboratively within a multidisciplinary team.
* Competent in clinical IT systems and documentation.
* Must hold full UK Driving License
Desirable
* Experience within a Primary Care Network (PCN)
* Experience in managing own caseload
Person Specification
Qualifications
Essential
* Registered Nurse (Adult) with valid NMC registration
* Clinical skills qualification
Desirable
* Non-medical prescribing qualification or willingness to work towards
* Post-registration qualification in frailty, older peoples care, or long-term conditions management
Experience
Essential
* Minimum of 2 years post registration experience in primary or community care
* Post-registration experience working with older people and/or patients living with frailty
* Experience delivering Year of Care reviews
* Experience managing patients with long-term conditions and complex needs
* Experience of holistic assessment and care planning
* Strong communication and consultation skills.
* Ability to work autonomously and collaboratively within a multidisciplinary team.
* Competent in clinical IT systems and documentation.
* Must hold full UK Driving License
Desirable
* Experience within a Primary Care Network (PCN)
* Experience in managing own caseload
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).
Employer details
Employer name
Denton Park Medical Group
Address
Denton Park Health Centre
West Denton Way
Newcastle Upon Tyne
NE5 2QW
Employer's website
(Opens in a new tab)
Employer details
Employer name
Denton Park Medical Group
Address
Denton Park Health Centre
West Denton Way
Newcastle Upon Tyne
NE5 2QW
Employer's website
(Opens in a new tab)