About this role
Job summary
An exciting opportunity has arisen to join Dartford MODEL PCN as a Frailty Nurse, supporting the delivery of our new Single Neighbourhood programme. Working across our member practices, patients' own homes and care home settings, you will play a key role in providing proactive, person-centred care for adults living with frailty and complex health needs. As part of a supportive multidisciplinary team, you will undertake comprehensive geriatric assessments, coordinate care, promote anticipatory care planning and work collaboratively to improve patient outcomes and help reduce avoidable hospital admissions. This is an excellent opportunity for an enthusiastic and compassionate nurse who enjoys autonomous working, values integrated care and is passionate about improving the lives of frail/older people.
The post is funded through the Single Neighbourhood programme and is offered as a fixed-term contract for 7 months in the first instance, with the potential for extension subject to ongoing funding and service requirements.Interviews planned to take place W/C 31st August 2026
Main duties of the job
The Frailty Nurse will play a key role in delivering the Single Neighbourhood (SNH) programme across the Primary Care Network. Working as part of a multidisciplinary team, the post holder will provide proactive, holistic care for patients living with frailty and complex health needs, with a particular focus on housebound patients, care home residents, patients receiving palliative care and those identified through the PCN's frailty registers.
The post holder will undertake comprehensive geriatric assessments (CGAs), coordinate care, support anticipatory care planning and work collaboratively with patients, carers and partner organisations to improve patient outcomes, promote independence and reduce avoidable emergency department attendances and hospital admissions.
About us
Dartford MODEL Primary Care Network is a forward-thinking and collaborative organisation serving a population of around 34,000 patients across three GP practices in Dartford, North Kent: The Wellcome Practice, Lowfield Medical Centre and Dr C J Shimmins & Partners.
We are committed to delivering high-quality, patient-centred care through multidisciplinary working, innovation and continuous service improvement. Our established team includes GPs, Clinical Pharmacists, Pharmacy Technicians, Physiotherapists, Paramedics, Care Coordinators, GP Assistants and other roles, working together to provide integrated care for our local population
Job description Job responsibilities
Main Duties and Responsibilities
Clinical Responsibilities
Deliver high-quality, patient-centred nursing care for patients living with frailty across GP practices, patients' own homes and care home settings. Undertake comprehensive geriatric assessments (CGAs), assessing patients' physical, psychological, functional and social needs, and contribute to personalised care planning. Develop and review anticipatory care plans in partnership with patients, carers and the multidisciplinary team. Monitor patients with frailty and complex needs, identifying changes in health status and escalating concerns appropriately. Recognise and manage common frailty syndromes including falls, delirium, immobility, continence issues, malnutrition and medication-related problems. Assess nutritional risk where appropriate and work collaboratively with dietitians, pharmacists and other healthcare professionals to optimise nutritional care. Work alongside the PCN pharmacy team and other prescribers to support structured medication reviews and medicines optimisation. Carry out cognitive assessments where appropriate and make timely referrals to memory assessment services and other specialist services in accordance with local pathways. Identify patients who may benefit from a palliative approach to care and facilitate referrals to appropriate services. Support patients and clinicians with ReSPECT discussions and documentation, ensuring patients' wishes are appropriately recorded. Undertake and record NEWS2 observations where clinically indicated, recognising deterioration and escalating concerns promptly. Record patients' preferred place of care and preferred place of death where appropriate. Care Coordination
Coordinate care for patients with frailty and complex needs, ensuring continuity across primary, community and secondary care services. Promote proactive management by identifying patients at risk of deterioration and supporting interventions to reduce avoidable emergency department attendances and hospital admissions. Support timely follow-up following hospital discharge or significant clinical events where appropriate. Liaise with patients, carers and families, providing education, support and signposting to appropriate health, social care and voluntary sector services. Multidisciplinary Working
Work collaboratively within multidisciplinary team (MDT) meetings, contributing to case discussions and coordinated care planning. Develop effective working relationships with GPs, pharmacists, community nurses, therapists, geriatricians, social care, care home staff, hospices and voluntary sector organisations. Support delivery of the Enhanced Health in Care Homes (EHCH) model through collaborative working with care home teams and community services. Quality, Governance and Service Development
Support practices with frailty identification, dementia and palliative care coding, ensuring accurate clinical records. Maintain accurate, contemporaneous documentation using EMIS Web and ensure appropriate clinical coding. Contribute to clinical audit, service evaluation, quality improvement initiatives and data collection to support delivery of the Single Neighbourhood programme. Participate in reporting requirements and service evaluation, including preparation of information for the ICB where required. Ensure compliance with CQC standards, safeguarding policies, NICE guidance and local clinical policies. Participate in mandatory training, clinical supervision, appraisal and continuing professional development. Practise in accordance with the NMC Code and maintain professional registration at all times. General Responsibilities
Maintain patient confidentiality and comply with GDPR and Information Governance requirements. Work flexibly across the PCN to meet service needs.
Undertake any other duties commensurate with the grade of the post
Person Specification
Knowledge & Skills Essential
Understanding of frailty and Comprehensive Geriatric Assessment (CGA) Knowledge of long-term condition management Knowledge of safeguarding adults Understanding of dementia, delirium and end of life care Knowledge of NEWS2 and recognition of deterioration Understanding of ReSPECT and advance care planning Excellent communication and interpersonal skills Ability to undertake holistic clinical assessments Ability to prioritise workload and manage a caseload independently Strong organisational and time management skills Ability to work collaboratively across organisational boundaries Competent IT skills, including electronic patient record systems (e.g. EMIS Web) Accurate clinical documentation and coding
Desirable
Advanced clinical assessment skills
Experience Essential
Experience working with older people and/or patients living with frailty Experience undertaking holistic patient assessments Experience managing patients with multiple long-term conditions Experience of multidisciplinary working Experience of care planning and care coordination
Desirable
Experience within Primary Care Community or District Nursing experience Care home nursing experience Experience of the Enhanced Health in Care Homes (EHCH) model Experience of quality improvement or service development
Personal Attributes Essential
Compassionate, caring and patient-centred Flexible and adaptable Able to work independently and as part of a multidisciplinary team Committed to continuous professional development and service improvement Professional, approachable and resilient
Qualifications Essential
Registered nurse with current NMC registration Evidence of continuing professional development
Desirable
Independent Prescribing qualification Degree in Nursing Community Nursing qualification Practice Assessor/Mentor qualification
Other Essential
Full UK driving licence and access to a vehicle (or ability to travel independently across the PCN) Willingness to work across multiple sites including GP practices, patients' homes and care homes
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 The Wellcome Practice
Address Dartford West Health Centre
Tower Road
Dartford
DA1 2HA
United Kingdom
Employer's website https://www.thewellcomepractice.nhs.uk/ (Opens in a new tab)