PCN Frailty Nurse

An exciting opportunity has arisen for an experienced and motivated nurse to join our newly established Primary Care Network Frailty Team as a Band 6 equivalent Frailty Nurse. This is an excellent time to join the service as it continues to grow and shape its model of care.

We are seeking a highly motivated and passionate individual with a strong interest in frailty care, committed to improving outcomes and enhancing quality of life for older people living with frailty. The successful candidate will demonstrate enthusiasm for delivering person-centred, proactive care and working collaboratively within a multidisciplinary team to provide high-quality, holistic support. The role will also contribute to the delivery of the Network Contract Local Enhanced Service (LES) requirements and support the ongoing development of high-quality frailty pathways across the PCN.

The post holder will play a key role in delivering proactive, person-centred care to patients living with mild frailty and those presenting with frailty syndromes. The role will focus on undertaking frailty assessments and structured Year of Care reviews within patients homes, working as part of the Frailty Team under the supervision of the Frailty Advanced Nurse Practitioner. The post holder will support early identification of risk, prevention of deterioration, and improved patient outcomes.

Key Responsibilities

Undertake frailty assessments encompassing physical, psychological, functional, and social domains.

Deliver structured Year of Care reviews for housebound patients, ensuring holistic, person-centred care planning.

Assess and manage patients presenting with frailty syndromes, including falls, immobility, delirium, incontinence, and polypharmacy.

Develop, implement, and regularly review personalised care plans in partnership with patients, carers, and the multidisciplinary team.

Support advanced care planning, anticipatory care, and self-management education to promote independence and prevent deterioration.

Recognise early signs of clinical deterioration, initiate appropriate interventions, and escalare concerns in line with local pathways and professional accountability.

Work autonomously across multiple GP practices within the PCN, liaising effectively with community, voluntary, and secondary care services.

Participate in and, where appropriate, lead Frailty MDT meetings to coordinate patient care and support shared decision-making.

Contribute to service development, audit, quality improvement initiatives, and the ongoing evaluation of the Frailty Team model.

Provide clinical guidance, supervision, and support to junior staff and lower band team members.

Support the Frailty Team Lead in the delivery, coordination, and ongoing development of the Frailty Service.

We are a network of six GP practices located in the west of Newcastle upon Tyne, brought together to form the Outer West Primary Care Network (PCN).

The practices in the Outer West have a strong history of working collaboratively, formalised through the creation of the PCN in 2019 as part of NHS Englands focus on delivering care tailored to local communities. The PCN provides a range of services to patients registered at its member practices, supporting proactive, coordinated, and person-centred care across the local population.

As part of its commitment to supporting older patients, the PCN has recently established a Frailty Team, focused on early identification, proactive management, and holistic care for people living with frailty. The team works across all six practices, fostering collaboration, sharing expertise, and developing innovative frailty pathways to improve outcomes and quality of life for this patient group.

Patient Care & Clinical Management:

Undertake holistic frailty assessments, including history taking and simple investigations

Recognise and act on situations potentially detrimental to patient health and well being.

Provide ongoing management of long-term conditions such as diabetes, COPD, hypertension, and cardiovascular disease.

Support and advise patients on health promotion, illness prevention, and…