About this role
Job summary
An exciting opportunity has arisen for an experienced Registered Nurse to join Welwyn Garden City PCN as a Frailty Nurse. Working 3 days a week across two of our member surgeries, you will lead on the proactive identification, review, and management of frail patients, deliver weekly ward rounds at two local care homes, and represent frailty patients at the monthly Integrated Neighbourhood Team (INT) Multidisciplinary Team (MDT).
This role is central to our PCN's frailty strategy, working closely with GPs, care home staff, the wider INT, and community services to deliver proactive, person-centred care that helps frail and elderly patients stay well and supported in their usual place of residence.
Main duties of the job
Undertake proactive comprehensive geriatric assessments and structured medication reviews for patients identified as moderately to severely frailDevelop and maintain personalised care and support plans with patients, carers, and familiesDeliver weekly ward rounds at two local care homes, providing clinical review, care planning, and liaison with care home staffIdentify and manage patients at risk of unplanned hospital admission, working proactively to anticipate and prevent crisesPresent complex and high-risk patients on a monthly basis at the INT MDT, coordinating input from wider health and social care partnersWork closely with GPs, PCN pharmacists, social prescribers, and community teams to ensure coordinated, joined-up careSupport advance care planning conversations, including ReSPECT and end-of-life discussions where appropriate
Maintain accurate clinical records and contribute to PCN frailty data and outcome reporting
About us
Welwyn Garden City PCN brings together a group of three local GP practices working collaboratively to deliver proactive, coordinated care to our patient population. We are expanding our multidisciplinary team and offer a supportive environment with strong links across general practice, community services, and social care.
Job description Job responsibilities Job Purpose
The PCN Frailty Nurse will work as part of the Primary Care Network's multidisciplinary team to proactively identify, assess, and manage patients living with frailty. The post-holder will provide structured clinical review for frail patients across two PCN member practices, deliver weekly ward rounds at two local care homes, and represent the frailty caseload at the monthly Integrated Neighbourhood Team (INT) Multidisciplinary Team (MDT) meeting.
The role is designed to reduce avoidable hospital admissions, improve continuity of care for frail and elderly patients, and strengthen coordination between general practice, care homes, and wider community and social care services.
Key Working Relationships GPs and clinical staff across PCN member practices Care home managers and nursing/care staff Integrated Neighbourhood Team (INT) members, including community nursing, palliative care teams, social care, and mental health services PCN Clinical Pharmacists and Social Prescribing Link Workers Patients, families, and informal carers Secondary care and discharge teams, as needed Main Duties and ResponsibilitiesClinical Care
Proactively identify patients with moderate to severe frailty using recognised frailty indices and practice registers Undertake comprehensive geriatric assessments (CGA), including functional, cognitive, social, and medication review Develop, document, and regularly review personalised care and support plans in partnership with patients, families, and carers Identify patients at risk of unplanned hospital admission and initiate proactive interventions to reduce that risk Support patients and families with advance care planning discussions, including ReSPECT forms and end-of-life wishes, escalating to GPs or specialist palliative services as appropriate Recognise and respond appropriately to signs of clinical deterioration, escalating to GPs or emergency services where necessary Care Home Ward Rounds
Deliver structured weekly ward rounds at two designated local care homes Review resident health status, medication, and care plans in collaboration with care home staff Liaise with GPs to action clinical decisions arising from ward rounds Build strong working relationships with care home managers and staff to support early identification of resident health concerns Multidisciplinary Working
Present complex and high-risk frailty patients at the monthly INT MDT meeting, providing clinical summaries and care plan updates Coordinate input and follow-up actions from MDT discussions across relevant services Work collaboratively with PCN pharmacists, social prescribers, and community teams to deliver joined-up, patient-centred care Act as a point of clinical liaison between general practice and community/social care services for frailty patients Administration and Governance
Maintain accurate, timely clinical records in line with practice and PCN information governance policies Contribute to PCN frailty data collection, audit, and outcome reporting Participate in relevant clinical audits and quality improvement initiatives Attend PCN and practice meetings as required Professional Development
Maintain NMC registration and up-to-date clinical competencies Participate in regular clinical supervision, appraisal, and revalidation processes Undertake training relevant to frailty, gerontology, and long-term condition management Keep up to date with national and local guidance relevant to frailty care (e.g. NICE, BGS, local ICB pathways) Confidentiality and Information GovernanceThe post-holder must maintain strict confidentiality regarding patient, staff, and organisational information in line with the Data Protection Act 2018, UK GDPR, and Caldicott principles.
Health and SafetyThe post-holder is required to comply with the PCN and host practices' health and safety policies, including infection control, safe manual handling, and lone-working procedures where relevant to care home and community visits.
Equality and DiversityThe post-holder must act in accordance with the PCN's equality, diversity, and inclusion policies, treating patients, carers, and colleagues with dignity and respect at all times.
Variation to This Job Description
This job description reflects the current requirements of the role. As the PCN's frailty service develops, the responsibilities may be reviewed and amended in consultation with the post-holder.
Person Specification
Experience Essential
Significant post-registration nursing experience Experience working with frail, elderly or complex patients in community settings Experience presenting at or contributing to MDT meetings
Desirable
Experience of working in a general practice setting Experience of working in a care home setting
Other Requirements Essential
Full UK Driving Licence and access to vehicle for travel between practices, care homes and patient homes.
Qualifications Essential
Registered Nurse with current NMC registration Level 7 Frailty Qualification
Desirable
Independent Prescribing Qualification Other long-term condition qualifications
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.
UK Registration
Applicants must have current UK professional registration. For further information please see NHS Careers website (opens in a new window).
Employer details Employer name Peartree Group Practice
Address 110 Peartree Lane
Welwyn Garden City
Hertfordshire
AL7 3UJ
United Kingdom
Employer's website https://www.peartreegp.co.uk/ (Opens in a new tab)