Overview
We are seeking an experienced and motivated Frailty Nurse to support the delivery of a proactive frailty service within our GP practice.
This role focuses on identifying, assessing and managing patients living with moderate to severe frailty, with the aim of improving patient outcomes, reducing avoidable admissions, and supporting patients to remain safely at home.
The successful candidate will work as part of a multidisciplinary team and play a key role in delivering structured frailty reviews in line with current contractual requirements.
This is not a routine treatment room role. The post holder will be expected to work autonomously, manage a defined cohort of patients, and take ownership of the frailty workload within the practice.
A significant proportion of the role will involve home visits and managing complex patients in the community.
Main duties of the job
Key Responsibilities
* Undertake comprehensive frailty assessments, including home visits where required
* Complete initial and follow up frailty reviews in line with the supplementary service requirements
* Develop and implement personalised care plans in collaboration with patients, carers and the wider MDT
* Identify and manage clinical risk, including falls risk, polypharmacy concerns and safeguarding issues
* Work closely with GPs, pharmacists, community teams and external providers to coordinate care
* Support proactive case management of high risk patients
* Maintain accurate and contemporaneous clinical records using EMIS
* Contribute to service development and improvement of frailty pathways within the practice
About us
Brynteg Surgery is a forward thinking, training GP practice based in Ammanford, serving a patient population of approximately 11,000 across two sites.
We operate as an independent GP partnership within NHS Wales and place a strong focus on running a well organised, sustainable service that supports both patients and staff.
Over recent years, the practice has invested significantly in modernising systems and improving patient access. This includes the use of digital triage, online consultation tools, automated telephony, and self check in options to reduce pressure on reception and improve patient flow.
We have a well established multidisciplinary team including GPs, nursing staff, pharmacists and administrative teams, and we actively promote working at the top of role. Our approach is to ensure that clinical workload is shared appropriately, allowing clinicians to focus on the work they are best placed to deliver.
As a training practice, we are committed to developing staff and supporting learners within primary care. We encourage new ideas, continuous improvement, and practical solutions to the day to day challenges of general practice.
We recognise the increasing demand associated with an ageing population and are developing our frailty service to provide more proactive, structured care for patients with complex needs. This role is a key part of that model.
Job details
Title: Frailty Nurse
Hours: 2 days per week
Location: Brynteg Surgery, Ammanford, covering both practice sites and patient homes
Job Purpose: To deliver a proactive, structured frailty service within the practice, focusing on the identification, assessment and ongoing management of patients living with moderate to severe frailty.
The post holder will work autonomously to manage a defined cohort of patients, with the aim of improving patient outcomes, reducing avoidable hospital admissions, and supporting patients to remain safely within the community.
Clinical Responsibilities
* Undertake comprehensive frailty assessments, including home visits where appropriate
* Identify patients suitable for the frailty service and prioritise workload based on clinical need
* Develop, implement and review personalised care plans
* Complete initial and follow up frailty reviews in line with service requirements
* Assess and manage clinical risk including falls, polypharmacy concerns and safeguarding
* Escalate complex or high risk cases appropriately to GPs or wider MDT
Care Coordination
* Work collaboratively with GPs, pharmacists, district nurses, community teams and secondary care services
* Act as a key point of contact for patients within the frailty cohort
* Support proactive case management of high risk and vulnerable patients
* Liaise with carers and family members where appropriate
Service Delivery
* Contribute to the development and ongoing improvement of the practice frailty service
* Support delivery of contractual requirements relating to frailty care
* Ensure activity is appropriately coded and recorded to support service monitoring and claims
Administration and Record Keeping
* Maintain accurate, contemporaneous and high quality clinical records using EMIS
* Ensure all patient interactions and care plans are clearly documented
* Contribute to audits, reporting and service evaluation as required
Professional Responsibilities
* Work within NMC Code of Conduct and maintain professional registration
* Maintain up to date clinical knowledge relevant to frailty and long term condition management
* Participate in relevant training and continuing professional development
* Adhere to practice policies including safeguarding, infection control, and information governance
General
* Work flexibly across both practice sites
* Undertake home visits as a routine part of the role
* Support the wider team as required in delivering safe and effective patient care
Accountability
The post holder will be accountable to the Practice Manager and GP Partners.
Contract Type
This post is initially offered on a fixed term basis linked to current service funding, with the potential for extension subject to ongoing service need and funding.
Other Requirements
* Full UK driving licence and access to a vehicle
* Willingness to undertake home visits as a routine part of the role
* Ability to work across both practice sites
Knowledge and skills
* Strong clinical assessment and decision making skills
* Ability to work autonomously and manage a defined caseload
* Ability to identify and manage clinical risk
* Good understanding of safeguarding and risk management
* Effective communication skills with patients, carers and professionals
* Ability to prioritise workload and work flexibly in a changing environment
* Knowledge of frailty pathways and community services
* Understanding of primary care systems and processes within NHS Wales
* IT literacy including use of clinical systems such as EMIS
Qualifications
* Registered Nurse with valid NMC registration
* Additional training in frailty, geriatrics or long term condition management
Experience
* Experience of working with elderly or frail patients in a community, primary care or similar setting
* Demonstrable experience of clinical assessment and care planning
* Experience of managing patients with complex health and social needs
* Experience of working within a GP practice
* Experience of case management or care coordination
* Experience of working within multidisciplinary teams across organisational boundaries
Personal Attributes
* Confident and self motivated, with the ability to work independently
* Organised and able to manage competing demands
* Professional, reliable and accountable
* Able to build effective working relationships across teams
* Commitment to delivering high quality patient care
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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