Oxford Terrace and Rawling Road Medical Group
Frailty Nurse
The closing date is 05 May 2026
A fantastic opportunity has arisen for a Frailty Nurse to join our team. You will be working alongside two experienced Frailty Nurses within our Complex Care Team.
The role is 30 hours per week, worked over four days, and is based at our Rawling Road Practice. This is an excellent opportunity to further develop and build on your existing skills within a supportive and friendly multidisciplinary team.
Oxford Terrace and Rawling Road is a busy, welcoming practice located within a diverse community, caring for a registered population of approximately 17,632 patients. We are a well established multidisciplinary team and a teaching practice, committed to delivering high quality patient care while supporting learning and development. Our team is made up of GP's, Advanced Nurse Practitioner, Pharmacists, Practice Nurses, Frailty Nurses, Nurse Associates and Healthcare Assistants all working collaboratively to provide comprehensive, patient centred care.
Main duties of the job
The Frailty Nurse will play a key role in delivering proactive, person-centred care to adults living with frailty, dementia, or requiring a palliative approach. Working as part of the neighbourhood multidisciplinary team (MDT), the postholder will identify, assess, and manage patients across primary care, and community settings to optimise quality of life, reduce avoidable hospital admissions, and support patients and their families in planning for future care needs.
Job responsibilities
* Undertake systematic case finding and risk stratification using recognised tools (eFI, CGA, Rockwood CFS, SPICT, GSF).
* Carry out comprehensive holistic assessments, including physical, psychological, functional, and social needs.
* Provide and update individualised care plans, including Emergency Health Care Plans (EHCPs), and liaise with system colleagues on end-of-life care plans and advance care planning.
* Conduct and document structured medication reviews, working with pharmacists and prescribers to reduce polypharmacy and inappropriate prescribing. (Only if prescribing clinician)
* Perform cognitive assessments and make timely referrals to Memory/Dementia Services where indicated.
* Identify patients requiring a palliative approach and initiate supportive care interventions with other services.
* Monitor and manage frailty syndromes (falls, delirium, incontinence, immobility, medication-related issues) to prevent deterioration.
* Liaise with carers and families, providing education, support, and signposting to appropriate services.
* Work within and contribute to the multidisciplinary neighbourhood health team (including GPs, social workers, therapists, pharmacists, community nurses, geriatricians, and VCSE partners).
* Participate in MDT meetings, case discussions, and joint care planning.
* Develop strong, collaborative links with system colleagues, ensuring continuity of care and effective communication.
* Support practices to establish and follow protocols for frailty, dementia, and palliative care identification and coding.
* Promote early recognition of patients at risk of deterioration, ensuring proactive rather than reactive care.
* Ensure compliance with CQC essential standards, safeguarding policies, and NICE guidance.
* Maintain accurate and timely patient records in line with local coding requirements (SNOMED codes for frailty, dementia, palliative care, ACP discussions, SMRs).
* Contribute to audits, data submissions, and service evaluation, including preparation of reports for ICB monitoring.
Outcomes & Impact
* Reduction in avoidable A&E attendances, 111 calls, OOH contacts, and non-elective admissions.
* Improved recording and recognition of frailty, dementia, and palliative care needs.
* Increased uptake of structured medication reviews and personalised care plans.
* More patients achieving their preferred place of care and place of death.
* Enhanced quality of life, autonomy, and dignity for patients.
Professional Responsibilities
* Maintain NMC registration and comply with professional codes of conduct.
* Engage in clinical supervision, reflective practice, and continuing professional development (CPD).
* Support training and development of colleagues in frailty and dementia awareness.
* Uphold safeguarding responsibilities and ensure the protection of vulnerable adults.
Person Specification
Experience
* Experience in community nursing, care of older adults, long-term conditions, or palliative care.
* Experience working in primary care or care home settings.
* Experience in quality improvement, service development, or audit.
Qualifications
* Registered Nurse with NMC registration.
* Non-medical prescribing qualification (V300) or willingness to undertake training.
Clinical Knowledge and Skills
* Knowledge of frailty assessment tools (eFI, Rockwood CFS, CGA) and care planning frameworks (SPICT, GSF).
* Strong communication and interpersonal skills with patients, carers, and MDT partners.
* Ability to work independently and as part of a multidisciplinary team.
* Competence in electronic patient record systems and accurate documentation.
* Knowledge of safeguarding procedures and relevant NICE guidance.
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.
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