Job Summary
Totton Primary Care Network is seeking an experienced, motivated Frailty Nurse to join a multidisciplinary team and support proactive, high‑quality care for frail and elderly patients.
Responsibilities
* Undertake comprehensive frailty assessments, including clinical, functional, psychological and social aspects of care.
* Develop, implement and regularly review personalised care and support plans in collaboration with patients, carers and the wider MDT.
* Provide clinical reviews and ongoing monitoring for patients identified as moderately or severely frail.
* Support admission avoidance through early intervention, escalation planning and coordination with community and acute services.
* Contribute to anticipatory care planning, including end‑of‑life and advance care planning where appropriate.
* Work closely with GPs, ANPs, Care Coordinators, Social Prescribers, pharmacists and community teams.
* Participate in MDT meetings, case discussions and proactive care planning forums.
* Act as a clinical resource for frailty‑related advice within the PCN.
* Liaise with secondary care, community services and voluntary sector organisations to ensure seamless care pathways.
* Support quality improvement initiatives related to frailty and proactive care.
* Ensure accurate and timely clinical documentation in patient records.
* Maintain awareness of current best practice, guidelines and evidence relating to frailty care.
* Maintain NMC registration and adhere to the NMC Code of Professional Conduct.
* Take responsibility for professional development, mandatory training and revalidation processes.
* Work within PCN policies, procedures and governance frameworks.
Qualifications – Essential
* Registered Nurse with current UK NMC registration.
* Experience working with older adults and/or patients living with frailty.
* Experience of clinical assessment and care planning.
* Experience working within primary care, community services or a similar healthcare setting.
* Strong clinical assessment and decision‑making skills.
* Knowledge of frailty, long‑term conditions and proactive care approaches.
* Ability to work autonomously and manage a clinical caseload.
* Excellent communication and interpersonal skills, with the ability to work collaboratively within a multidisciplinary team.
* Good IT skills and ability to maintain accurate clinical records.
* Organised, flexible and adaptable approach to work.
* Patient‑centred and compassionate care mindset.
* Ability to manage workload effectively and prioritise competing demands.
* Commitment to equality, diversity and inclusion.
* Willingness to travel between PCN sites as required.
* Commitment to ongoing professional development.
* Disclosure and Barring Service (DBS) check and occupational health clearance.
* Hold a valid driving licence with own car and business insurance to use for home visits.
Qualifications – Desirable
* Experience of proactive or anticipatory care.
* Experience working with care homes or long‑term conditions.
* Experience of working within a PCN or MDT setting.
* Degree‑level qualification or equivalent experience.
* Non‑medical prescribing qualification or willingness to work towards it.
* Knowledge of PCN structures and DES requirements.
* Understanding of population health and personalised care.
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