Frailty Nurse

Key Responsibilities Clinical 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. Multidisciplinary & Collaborative Working 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. Service Development & Quality Contribute to the development and delivery of PCN frailty services in line with DES requirements. 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. Professional Responsibilities Maintain NMC registration and adhere to the NMC Code of Professional Conduct. Take responsibility for own professional development and mandatory training. Participate in clinical supervision, appraisal, and revalidation processes. Work within PCN policies, procedures, and governance frameworks.