About this role
Job summary
We are seeking an experienced and motivated Frailty Nurse to support a PCN with areas of high frailty.
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.
Please note, Gateshead Inner West PCN is not approved by the Home Office and is therefore not able to offer candidates support for an application for a Health and Care Visa.
If you would like to find out more about the role, we would be delighted to hear from you and answer any questions you may have.
Main duties of the job
Undertake comprehensive frailty assessments including home visits where required 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 escalating complex or high-risk cases appropriately to the GPs or wider MDT Maintain accurate and contemporaneous clinical records using EMIS, ensuring correct coding to ensure appropriate service monitoring and claims Contribute to service development and improvement of frailty pathways within the practice
About us
Based in the Inner West of Gateshead our Primary Care Network serves over 45,000 patients across our four member Practices of: Whickham Medical Cottage, Chainbridge Medical Partnership, Glenpark and Teams Medical Practice and Sunniside Surgery. We are motivated to provide high-quality care to the population we serve.
We have an established ARRS team including Social Prescriber Link Workers, Community Mental Health Practitioner's, Physiotherapists and Pharmacist's. Our Frailty nurse would be an essential addition to this team and expected to form close links with the wider PCN team.
Job description Job responsibilities
Key Duties
Undertake comprehensive frailty assessments including home visits where required 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 escalating complex or high-risk cases appropriately to the GPs or the wider MDT Maintain accurate and contemporaneous clinical records using EMIS, ensuring correct coding to ensure appropriate service monitoring and claims Contribute to service development and improvement of frailty pathways within the practice
Person Specification
Qualifications Essential
Registered Nurse with Nursing and Midwifery Council (NMC) registration MSc or equivalent in Advanced Clinical Practice Significant experience in primary care, community, or elderly care Advanced clinical assessment and decision-making skills Full UK Driving License
Desirable
Non-Medical Prescriber qualification (or working towards)
Experience Essential
Experience working with frailty pathways or geriatric populations Knowledge of Comprehensive Geriatric Assessment (CGA) Leadership or service development experience
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 Gateshead Inner West Primary Care Network
Address Glenpark Medical Centre
Ravensworth Road
Gateshead
Tyne And Wear
NE11 9FJ
Employer's website https://www.gatesheadinnerwestpcn.co.uk/ (Opens in a new tab)