Job Summary
The frailty nurse will work within their professional scope of practice in a general practice environment as part of our Primary Care Network (PCN). As a key member of the PCN ageing well team, they will play a key role in preventing avoidable hospital admissions and helping patients age well and better manage their conditions.
They will case-manage house bound patients with frailty and long-term conditions, promoting independence and supporting individuals to live well in their own homes. They will plan, implement and evaluate care for patients in our community, to meet patients' needs and preferences in the delivery of high-quality health care. Ensuring that the patient's needs and preferences are known and communicated at the right time to the right people.
In this fast-paced and rewarding role, they will be expected to work independently, exercising sound clinical judgment within the boundaries of their professional practice.
Working under the guidance of the Frailty Lead GP and ANP, the Frailty Nurse will receive daily support from Frailty Care Coordinators, Clinical Pharmacists, and the wider PCN.
Please note, a valid driving licence and access to your own vehicle are essential for this role.
Main duties of the job
Undertake clinical nursing practice using expert knowledge and clinical skills to deliver holistic care to patients living in their own home or care home.
Collaborate closely with GPs and work independently to deliver safe, effective care to frail and housebound individuals.
Promote / support health & wellbeing.
Facilitate patient education, self-management of disease, and behaviour modification.
Conduct thorough person-centred needs assessment to develop care plans.
Represent individuals and families interests when they are not able to do so themselves.
Maintain and regularly update a comprehensive register of frail patients.
Initiate the process of diagnosis with patients suspected to have a chronic disease.
Proactively manage long term conditions.
Accurately update patient records on SystmOne.
Communicate effectively with other healthcare professionals and make appropriate referrals to ensure coordinated, multidisciplinary care.
Attend multidisciplinary team (MDT) meetings.
Support HCAs / Care Coordinators
Operate in line with clinical protocols and guidelines, ensuring professional, compassionate support for patients, families, and carers.
Ensure compliance with practice CQC requirements and maintain accurate documentation.
Work within all relevant PCN practice policies and procedural guidelines
Take an active part in the planning and delivery of the PCN Covid programmes.
About Us
IMP Healthcare PCN Ltd are made up of 9 member GP practices in and around Lincoln serving 74,000 patients.
Details
Date posted
12 August 2025
Pay scheme
Other
Salary
Depending on experience
Contract
Permanent
Working pattern
Full-time, Part-time, Job share, Flexible working
Reference number
B0324-25-0007
Job locations
Commerce House Chamber Of Commerce Commerce House
Lincoln
LN2 2WJ
Job Description
Job responsibilities
Undertake clinical nursing practice using expert knowledge and clinical skills to deliver holistic care to patients living in their own home or care home.
Collaborate closely with GPs and work independently to deliver safe, effective care to frail and housebound individuals, including those residing in care homes.
Promote / support health & wellbeing, helping patients to remain independent and well at home.
Facilitate patient education, self-management of disease, and behaviour modification.
Undertake annual review of patients understanding and ability to self-manage
Conduct thorough person-centred needs assessment to develop care plans for each patient.
Represent individuals and families interests when they are not able to do so themselves.
Maintain and regularly update a comprehensive register of frail patients, utilising clinical frailty scoring tools to assess and monitor levels of frailty.
Initiate the process of diagnosis with patients suspected to have a chronic disease e.g., diabetes, COPD, asthma, IHD referring to other clinical staff as appropriate.
Proactively manage long term conditions.
Accurately update patient records on SystmOne. All documentation must be timely, relevant, and clearly reflect the care provided.
Directly admit patients to secondary care hospital in acute medical need.
Promote clear communication with the health care team and support medication management.
Communicate effectively with other healthcare professionals and make appropriate referrals to ensure coordinated, multidisciplinary care.
Build and communicate therapeutic working relationships with a wide array of statutory and voluntary organisations for the benefit of patient care and facilitates good working relationships.
Attend multidisciplinary team (MDT) meetings, fostering effective working relationships with health, social care, and third-sector partners to ensure a seamless, integrated response for patients with complex needs or long-term conditions.
Work flexibly across various healthcare settings, including surgeries, home visits, and community.
Actively participate in clinical, PCN and practice meetings as required.
Participate in team meetings, audits, and data collection for improving patient care.
Support HCAs / Care Coordinators in delivering high-quality care to frail and housebound patients.
Provide expert clinical advice and support to patients, carers, and colleagues, maintaining high standards of professional practice and clinical excellence.
Operate in line with clinical protocols and guidelines, ensuring professional, compassionate support for patients, families, and carers - using resources responsibly and efficiently.
Contribute to service development by creating and implementing innovative models, methods, and practices to enhance primary care services for the frail population.
Regularly communicate service-related information to the broad spectrum of staff within the PCN and its practices.
Ensure compliance with practice CQC requirements and maintain accurate documentation.
Work within all relevant PCN practice policies and procedural guidelines e.g., infection control, chaperoning, risk management.
Contribute to PCN practice targets both local and national
Contribute to disease registers.
Keep up to date with schemes and contractual agreements by liaising with Practice Managers, GPs and Integrated Care Board.
Develop own knowledge and practice to meet objectives/changes in service, through attendance on study days, self-directed learning, and reflection on practice.
Undertake all mandatory training required for the role
Participate in our appraisal system, matching organisational aims with individual objectives Maintain the highest standards of conduct and integrity.
Job Description
Job responsibilities
Undertake clinical nursing practice using expert knowledge and clinical skills to deliver holistic care to patients living in their own home or care home.
Collaborate closely with GPs and work independently to deliver safe, effective care to frail and housebound individuals, including those residing in care homes.
Promote / support health & wellbeing, helping patients to remain independent and well at home.
Facilitate patient education, self-management of disease, and behaviour modification.
Undertake annual review of patients understanding and ability to self-manage
Conduct thorough person-centred needs assessment to develop care plans for each patient.
Represent individuals and families interests when they are not able to do so themselves.
Maintain and regularly update a comprehensive register of frail patients, utilising clinical frailty scoring tools to assess and monitor levels of frailty.
Initiate the process of diagnosis with patients suspected to have a chronic disease e.g., diabetes, COPD, asthma, IHD referring to other clinical staff as appropriate.
Proactively manage long term conditions.
Accurately update patient records on SystmOne. All documentation must be timely, relevant, and clearly reflect the care provided.
Directly admit patients to secondary care hospital in acute medical need.
Promote clear communication with the health care team and support medication management.
Communicate effectively with other healthcare professionals and make appropriate referrals to ensure coordinated, multidisciplinary care.
Build and communicate therapeutic working relationships with a wide array of statutory and voluntary organisations for the benefit of patient care and facilitates good working relationships.
Attend multidisciplinary team (MDT) meetings, fostering effective working relationships with health, social care, and third-sector partners to ensure a seamless, integrated response for patients with complex needs or long-term conditions.
Work flexibly across various healthcare settings, including surgeries, home visits, and community.
Actively participate in clinical, PCN and practice meetings as required.
Participate in team meetings, audits, and data collection for improving patient care.
Support HCAs / Care Coordinators in delivering high-quality care to frail and housebound patients.
Provide expert clinical advice and support to patients, carers, and colleagues, maintaining high standards of professional practice and clinical excellence.
Operate in line with clinical protocols and guidelines, ensuring professional, compassionate support for patients, families, and carers - using resources responsibly and efficiently.
Contribute to service development by creating and implementing innovative models, methods, and practices to enhance primary care services for the frail population.
Regularly communicate service-related information to the broad spectrum of staff within the PCN and its practices.
Ensure compliance with practice CQC requirements and maintain accurate documentation.
Work within all relevant PCN practice policies and procedural guidelines e.g., infection control, chaperoning, risk management.
Contribute to PCN practice targets both local and national
Contribute to disease registers.
Keep up to date with schemes and contractual agreements by liaising with Practice Managers, GPs and Integrated Care Board.
Develop own knowledge and practice to meet objectives/changes in service, through attendance on study days, self-directed learning, and reflection on practice.
Undertake all mandatory training required for the role
Participate in our appraisal system, matching organisational aims with individual objectives Maintain the highest standards of conduct and integrity.
Person Specification
Qualifications
Essential
* Nursing qualification
* NMC registration
Desirable
* Experience of working in Primary Care
Experience
Essential
* Experience of working in a nursing team
Desirable
* Experience of working in Primary Care and or General practice
* Systmone experience
* Experience of working with patients on the Frailty register
* Experience carry out home visits
* Long term condition qualification or experience. Asthma, COPD, Diabetes, Heart disease
Person Specification
Essential
* Experience of working in a nursing team
Desirable
* Experience of working in Primary Care and or General practice
* Systmone experience
* Experience of working with patients on the Frailty register
* Experience carry out home visits
* Long term condition qualification or experience. Asthma, COPD, Diabetes, Heart disease
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
Imp Federation Ltd
Address
Commerce House Chamber Of Commerce Commerce House
Lincoln
LN2 2WJ
Employer's website
http://imphealthcare.co.uk/ (Opens in a new tab)
Employer details
Employer name
Imp Federation Ltd
Address
Commerce House Chamber Of Commerce Commerce House
Lincoln
LN2 2WJ
Employer's website
http://imphealthcare.co.uk/ (Opens in a new tab)
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