PCN Frailty Nurse
The closing date is 05 July 2026
Our PCN is looking for a Frailty Nurse (band 7 equivalent), who will provide expert clinical oversight and specialist nursing care for residents living within care homes served by one of our largest practices, Marine Lake Medical Practice. The postholder conduct weekly ward rounds across designated care homes, working collaboratively with GPs, pharmacists, care home staff, community services and the wider multidisciplinary team within the practice.
Main duties of the job
The role focuses on acute care, as well as proactive frailty management. The post holder will complete comprehensive assessments, anticipatory care planning, medicines optimisation, prevention of avoidable hospital admissions, and delivery of person-centred care for older people with complex needs.
They will act as a key clinical resource for care home staff and the wider primary care team, supporting the delivery of high-quality, safe and effective care to the practice's care home population.
This is a highly rewarding role that offers the opportunity to make a meaningful difference to the lives of some of our most vulnerable patients. The successful candidate will have the time and continuity to build strong, trusted relationships with residents, their families and care home staff, enabling truly personalised care and improved health outcomes.
About us
Healthier West Wirral Primary Care Network (PCN) is a forward-thinking organisation serving a population of approximately 70,000 patients across five member GP practices. We employ over 50 dedicated staff who form a highly skilled and supportive multidisciplinary team (MDT), working collaboratively to deliver high-quality, patient-centred care within our local communities. As a CQC-registered organisation, we are committed to delivering safe, effective, and innovative services that support the NHS vision for neighbourhood health and the ambitions set out in the 10-Year Health Plan. Our team brings together a diverse range of clinical and non-clinical professionals, creating an inclusive and dynamic working environment focused on improving outcomes for our population and reducing health inequalities across West Wirral.
Job responsibilities
Key Responsibilities
Clinical Leadership
Lead weekly care home ward rounds and MDT meetings across designated care homes.
Undertake comprehensive holistic assessments of residents with frailty, multiple long-term conditions and complex care needs.
Develop, implement and evaluate personalised care plans in partnership with residents, families, care home staff and practices care home Physician Associate.
Provide expert clinical advice and support regarding frailty, dementia, end-of-life care and complex nursing needs.
Identify residents at risk of deterioration and coordinate timely interventions to prevent avoidable hospital admissions.
Support the identification and management of residents requiring enhanced health support, including those approaching end of life.
Promote shared decision-making and person-centred care throughout all interactions.
Care Home MDT Working
Work collaboratively within the practice's care home MDT, including GPs, pharmacists and physician associates.
Coordinate care and facilitation effective communication between all agencies involved in resident care.
Participate in multidisciplinary case reviews and clinical discussions.
Ensure actions arising from ward rounds are appropriately implemented and followed up.
Develop strong working relationships with care home managers and staff to support integrated care delivery.
Frailty and Long-Term Condition Management
Lead on proactive frailty identification, assessment and management.
Support delivery of comprehensive geriatric assessment principles within care homes.
Undertake clinical reviews for residents with complex long-term conditions.
Contribute to anticipatory care planning, treatment escalation planning and advance care planning discussions.
Support residents to maintain independence, function and quality of life wherever possible.
Quality Improvement and Service Development
Contribute to the ongoing development and improvement of care home services.
Support achievement of national and local care home and enhanced health in care home objectives.
Participate in clinical audit, service evaluation and quality improvement initiatives.
Monitor clinical outcomes and identify opportunities to improve resident care and experience.
Support implementation of evidence-based practice and national guidance relating to frailty and care home medicine.
Support the practice with work relating to research programmes, where they link to patients in care homes.
Education and Support
Provide clinical education and support to care home staff.
Deliver training relating to frailty, deterioration management, long-term conditions, end-of-life care and clinical best practice, when required.
Act as a clinical role model and source of expertise within the PCN.
Support the professional development of colleagues and students where appropriate.
Governance and Professional Responsibilities
Maintain accurate, contemporaneous and legally compliant clinical records.
Work within NMC Code standards and professional scope of practice.
Ensure safeguarding concerns are identified, escalated and managed appropriately.
Participate in clinical supervision, appraisal and continuing professional development.
Person Specification
Qualifications
* Registered Nurse with current NMC registration.
* Degree-level nursing qualification or equivalent experience.
* Evidence of continuing professional development.
* Ability to prioritise workload and work autonomously.
* Experience of working with older adults and people living with frailty.
* Experience of managing complex patients with multiple long-term conditions.
* Advanced clinical assessment qualification.
* Postgraduate qualification in frailty, gerontology or advanced practice.
* Experience working within primary care.
* Experience in quality improvement, audit or service development.
Personal Attributes
* Compassionate and person-centred approach.
* Professional credibility and clinical leadership.
* Ability to work collaboratively across organisational boundaries.
* Commitment to continuous improvement and high standards of care.
* Flexible and adaptable approach to service needs.
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.
Healthier West Wirral Primary Care Network
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